Complete and submit this form AFTER you have successfully completed ALL of the learning required for your placement on the previous webpage. By submitting this form you verify that you have completed: You must have JavaScript enabled to use this form. First name Last name Date of birth Email Please enter your role title: Elective/Placement start date: Elective/Placement location: - Select -LHSCSt. Joseph'sTo be determined Privacy and Confidentiality Declaration: I acknowledge and agree to the Privacy and Confidentiality responsibilities and have reviewed and the Privacy and Confidentiality Agreement Statement Online Required Learning Training Declaration: I acknowledge the completion of all required learning education modules. Patient Care Systems Training Declaration: I acknowledge, if applicable, that I have registered for an Electronic Health Records training class or completed the FirstNet online training
