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A: Position Being Applied For
*Job Title:
*Competition No.:
B: Personal Data
*Last Name:
*First Name:
*Address:
*City:
*Province:
*Postal Code:
*Home Telephone No.:
*Other Contact Telephone No.:
*Email: **A confirmation that we received your application will be sent to this email address **
C: Student Profile
Institution:
Program:
Current Year:
Clinical Experience(s):
HSPnet Reference Number (If Applicable):
D: Placement Details
*Placement Term Requested: (Please select only one):


Start Date (Please enter DD-Mon-YYYY):
End Date (Please enter DD-Mon-YYYY):
Placement Availability:




#Hours Per Week:
Length of Placement:
Academic Coordinator Name:
Academic Coordinator Phone:
Academic Coordinator Email:
Evaluation Plan:
*Will you have access to a vehicle during this placement? (i.e.: rent a car, carshare, own a car) :


E: Screening Questions for Student Placement
Region of Waterloo Public Health believes that when people live in a healthy and supportive community they will be able to make healthy choices. The department works in partnership with the community to enhance our Region's health with opportunities for all to reach their highest level of health.
*Does it pose a problem for you to support and project the values of our organization?:

On a daily basis you will likely be interacting with members of the public inquiring about or using our Public Health Services.
Do any of these other situations pose a problem for you?
*Providing service to people who are injection drug users or sex trade workers:

*Supporting women with all pregnancy options, including abortion:

*Providing service to young teens seeking birth control, or testing/treatment for STD or HIV exposure :

*Providing service to known HIV positive people:

*Providing service to people from all priority groups, for example, ethno cultural, gay/lesbian/bisexual/transgender, or people with disabilities:

*Providing service to people regarding the promotion of annual influenza immunization and other vaccines :

F: Additional Questions
We are currently only offering 2 placements for nursing students. The first area is Case and Contact, which involves speaking to people who have been testing for the COVID-19 virus, managing their case with daily calls and documentation, and doing contact tracing to determine who they may have exposed to the virus. The second area is Investigation and Outbreak, which involves supporting line lists and other aspects of supporting nursing homes, long term care homes and other similar settings with outbreak management, quarantine logistics, and investigation into the related IPAC measures.
*1. Please rank your preferences - we cannot guarantee your first choice, but will make our best effort to accommodate your preference if you are offered a placement.:
*2. What are you hoping to experience and learn more about while at Region of Waterloo Public Health and Emergency Services?:
*3. Please comment on what skills and/or strengths you bring to a placement at Region of Waterloo Public Health and Emergency Services.:
*4.What are your career goals when it comes to nursing and what type of nursing environment appeals to you?:
G: Read the following carefully before submitting
I hereby certify that the information given is true and correct to the best of my knowledge. I agree and understand that any misrepresentation of facts shall constitute just cause for the termination of my placement with Region of Waterloo Public Health at any time.
H: PH USE Only - Referred to:

Division: __________________________ Program: _______________________

Manager: __________________________ Staff Guide /Preceptor: ____________

Accepted: Yes  No  If No Reason: __________________________________
I: Cover Letter and Resume
*Cover Letter:
*Resume:

 

Region of Waterloo Public Health,
99 Regina Street S, 3rd Floor,
Waterloo, ON N2J 4V3
Phone:519-883-2002 ext. 5354