FACULTY OF NURSING

Notice Regarding Required Skills and Abilities

I, the undersigned, understand that as a student enrolled in the BN Program at the University of Calgary, Faculty of Nursing, I
require Requisite Skills and Abilities (RSAs) to progress through the BN Program.

RSAs are basic skills and abilities required by nursing students for progression through a nursing education program and for
initial entry-to-practice as a Registered Nurse. The College & Association of Registered Nurses of Alberta (CARNA) considers
RSAs fundamental to the provision of safe, competent and ethical nursing care in the best interest of the public.

There are seven categories of requisite skills and abilities:

1. Cognitive 5. Physical
2. Behavioural 6. Sensory Perceptual
3. Communication 7. Environmental
4. Interpersonal

Detailed information regarding RSAs, including examples, are outlined in the document “Requisite Skills and Abilities for
Becoming a Registered Nurse in Alberta”, CARNA, May 2011. This document is available online at:
https://nursing.ucalgary.ca/policies

It is important to note that the University of Calgary Academic Accommodation Policy does not require the University to
lower or substantially modify standards in order to accommodate students with disabilities. Adaptive technology and/or
academic accommodations are available to facilitate learning; however, they do not relieve students of their responsibilities
to develop the essential skills and abilities expected of all other students.

Please initial the following box:

Ia I affirm that I have read the document entitled “Requisite Skills and Abilities for Becoming a Registered Nurse in
Alberta”.

Choose one:

I affirm that I can meet the RSAs required to progress through the BN Program without requirement for
accommodation.

OR

I will require Academic Accommodation in order to meet the RSAs required to progress through the BN Program.
[Detailed information on Student Accessibility Services and the University of Calgary “Policy on Academic
Accommodations” can be found at: https://www.ucalgary.ca/access/]

Louise Navor
Student Name: ___________________________________ 30179710
UCID#: _______________________
(Please Print)

___________________________________ July, 14, 2022

Date: _________________________
(Student Signature)

April 26, 2019

UNDERGRAD REPORTS/FORMS – All Programs
 FACULTY OF NURSING

Notice Regarding Requirement for Police Information Checks - Student

I recognize that Alberta Health Services and other similar agencies or service providers require a Criminal
Record Check from every person engaged to provide care or support services under the Protection for
Persons in Care Act.
I understand that the Faculty of Nursing (the “Faculty”) contracts with Alberta Health Services and other
agencies to provide student practice placements and that under the terms of these contracts, the Faculty is
required to collect both a Criminal Record Check and a Vulnerable Sector Search (together the “Check”) from
every student admitted to the Faculty.
I understand that I will, therefore, need to present a current Check to the Faculty.
I understand that:
a) the Check must have been conducted within 3 months of the commencement of the program;
b) the Check must be presented to the Nursing Undergraduate Programs Office no later than one week
prior to the first day of classes:
i. via the electronic Police Information Check (ePIC) online system; or
ii. in person.
When the Check is presented in person, the Faculty Student Advisor will record when and where the Check
was conducted as well as the status of the Check. The original document will be returned to me.
I understand that failure to present the Check at least one week prior to the first day of classes may result in
retraction of my admission to the Faculty.
I also understand that if the Check results in a ‘not clear’ determination or if a criminal record conviction is
confirmed:
a) my admission to the Faculty may be retracted (new students); or
b) my program may be interrupted; or
c) I may be required to withdraw from the program (continuing students).
If I have a criminal record, I understand that I will have to provide a photocopy of the Check to the Faculty
and that the details contained within the Check may be disclosed to Alberta Health Services or other agencies
for the purpose of determining eligibility for participation in student practice placements. The photocopy will
be stored in a secure location and accessible only to those within the Faculty who have a need to know.
I am aware that if I am charged or convicted of a criminal offence at any time during my enrollment in the
program, I am required to inform the Faculty Undergraduate Program Office immediately.

Louise Navor
Student Name: ___________________________________ 30179710
UCID#: _______________________
(Please Print)

___________________________________ July 14 2022

Date: _________________________
(Student Signature)

Updated: April 26, 2019

Undergrad Reports/Police Info Checks
 FACULTY OF NURSING

Acknowledgement of Clinical Practice Expectations

I, the undersigned, understand that as a student enrolled in the Bachelor of Nursing Program at the University of Calgary,
Faculty of Nursing, I acknowledge the expectation of safe and ethical clinical practice expectations.

Clinical practice expectations are fundamental to the provision of safe, competent, and ethical nursing care in the best
interest of the public.

Please affirm the following by initialing the boxes and signing at the bottom of the page.

I affirm the following:

I have read the document entitled “Medication Preparation and Administration for Undergraduate Nursing
Students (Calgary Campus and Medicine Hat College Site)” and will adhere to the standards outlined in the
document.

I will engage in safe medication practices, and contribute to a culture of safety

I know the limits of own knowledge, skill, and judgment, and I will seek help

I will assess the appropriateness of the medication practice by considering the patient, the medication, and the
environment

I will adhere to Alberta Children’s Hospital expectations for direct supervision when administering medication

I have read the document entitled “Faculty of Nursing Use of Social Media” and will adhere to the standards
outlined in the document.

Louise Navor
Student Name: ___________________________________ 30179710
UCID#: _______________________
(Please Print)

___________________________________ July 14 2022

Date: _________________________
(Student Signature)

June 8, 2020
V:\FORMS - NU All Programs\Expectations of Safe Practices.docx
 Student Immunization/N95
Acknowledgement and Consent

All nursing students are required to complete a series of immunization and diagnostic tests as outlined on the Student
Immunization Worksheet. Required immunizations will follow Alberta Health Services (AHS) guidelines for learners
in place at the relevant time to enable participation in clinical placements at AHS sites. Documented proof of
completion must be provided to the Faculty of Nursing prior to commencement of the program.

Throughout the BN program, students are required to ensure that immunizations are current and must provide proof
of updates to the Faculty of Nursing. Students who do not have current and complete immunizations will not be able
to complete clinical placements required in the BN program. Immunization requirements may change during the
program. AC 3.1 Admissions

I hereby acknowledge:

1. That as a student in the University of Calgary, Faculty of Nursing Undergraduate Program, in order to meet the
program requirements and complete various onsite and offsite practicum components, I must be immunized against
and/or tested for communicable diseases and be N95 fit tested.

2. That the University of Calgary, Faculty of Nursing, has the right to withdraw me from a practicum site if the
University deems it to be in my best interest, or the best interests of those at the practicum site; or to set certain
standards and conditions that must be met before allowing me to enter upon or return to a practicum site.

3. That those entities (practicum providers) which host me at a practicum site have the right to withdraw the
opportunity for practicum at their sole discretion and to set standards and requirements for practicum experience.

4. That the University of Calgary, Faculty of Nursing, after consultation with the practicum providers and public health
authorities, have determined that in order to participate in practicum it is mandatory for students to be immunized
against/tested for:

Ø Covid 19, tetanus, diphtheria, pertussis, measles, mumps, rubella, varicella (if blood work or history do not
confirm immunity), Hepatitis B (confirmed with Hepatitis B antibody and other hep b blood tests depended
on risk factors) and tuberculosis (confirmed with mantoux testing). Exceptions may be made for valid,
documented medical and religious reasons.
Ø N95 fit tested. Exceptions may be made for valid, documented medical and religious reasons.

5. That as a practicum student, in choosing not to be immunized against seasonal influenza, or any other new
communicable disease not requiring mandatory immunization as a result of my practicum placement, I may be at
greater risk of contracting the illness for which the immunization is intended to prevent.

The University of Calgary, Faculty of Nursing, after consultation with practicum providers and public health
authorities, has determined that those students immunized against seasonal influenza, or any other new communicable
disease not requiring mandatory immunization, for reasons of health and safety, will have greater access to practicum
opportunities than those who are not. Choosing not to obtain the above-named non-mandatory immunization may
result in delay of practicum opportunity, or failure to complete the required practicum altogether resulting in failure
to graduate. Every reasonable effort will be made by the University of Calgary, Faculty of Nursing, to accommodate
me if I choose not to obtain the above-named immunization; however, the University of Calgary, Faculty of Nursing,
does not guarantee access to practicum in that event.

6. That falsification of any Immunization/N95 documents will result in immediate expulsion from the University of
Calgary, Faculty of Nursing Program.

Updated May 24, 2022

I hereby acknowledge the conditions related to the aforementioned information and consent that I will have all of the
mandatory immunizations/tests and N95 fit testing and accept all of the risks associated with choosing not to obtain
seasonal influenza immunization or any new communicable disease, such risks include, but are not limited to the delay
of, or failure to complete the practicum component of my program, illness or death.

Student Printed Name: Louise Navor

_____________________________ 30179710
ID#: _______________________

Student Signature: ____________________________ July 14 2022

Date: _______________________

Updated May 24, 2022

 CONFIDENTIALITY AGREEMENT (STUDENT)

Louise Navor
________________________________________ _________________________
30179710
Name of Participant (please print) Student ID #

□ BN Direct Entry Route (September Entry)

□ BN Transfer Route (September Entry)
□ BN Transfer Route (January Entry)
□ BN Degree Holder Route (January Entry)

As a nursing student at the University of Calgary, Faculty of Nursing, I will have the opportunity to
participate in clinical simulations. I understand the content of these simulations is to be kept
confidential to maintain the integrity of the learning experience for myself and fellow students. I also
understand that in working collaboratively during simulation scenarios, I will be witnessing others’
performances and I recognize that it would be unethical for me to share information regarding student
performance with persons outside of this setting.

Confidential simulation information is defined as anything that I, or those individuals with whom I
interact, would expect to remain private including information relating to:
• simulation scenarios/patients;
• standardized patients;
• patient models; and
• students

As a student, I am required to comply with the CSLC guidelines related to confidential information. I
understand that:
1. I may have access to confidential simulation information.
2. I am responsible for protecting all simulation information.
3. Confidentiality pertains to all formats: electronic, written, recorded, overheard or observed.
4. Confidential simulation information may only be used as needed to perform my assigned
activities. I may not:
a. share any simulation information with others outside of my clinical group and clinical
faculty
b. share or disclose specific simulation patient health information
c. share student performance with anyone other than those in my clinical simulation group
and clinical faculty
d. misuse or be careless about simulation information

By signing below, I acknowledge that I have read and understand the above and agree to abide by the
terms of this Agreement while enrolled in the BN Program.

____________________________________________ ___________________________
July 14 2022
Participant Signature Date

UNDERGRAD REPORTS\Forms-All Programs\CSLC Consent and Release Form (Student).Aug13-19

 FACULTY OF NURSING

SCHEDULE B

ACKNOWLEDGEMENT AND UNDERTAKING

TO: The Governors of the University of Calgary (the "University")

RE: Practicum – Faculty of Nursing

The undersigned hereby acknowledges that he/she is enrolled in the Faculty of Nursing (the
“Faculty”) and that, as part of his/her nursing studies, he/she will be undertaking clinical practice
learning experiences throughout the nursing program (the “Practicum”) at an agency (the “Agency”)
as determined by the University. The undersigned further acknowledges that this Practicum is
subject to the terms and conditions of a Practicum placement agreement between the University and
the Agency. In consideration of the University arranging with the Agency for the participation of the
undersigned in the Practicum at and with the Agency, the undersigned acknowledges to the
University and undertakes the following:

(a) that he/she shall undertake at the Agency only such activities as set out in an
Individual Practicum Placement Acknowledgement, specifically directed by the
Agency or the University and prepared prior to the commencement of his/her
Practicum;

(b) that he/she shall, in relation to information accessed in any way as a result of
enrolment in the Faculty:

(i) maintain strict confidentiality of any and all client or patient personal or health
care information or data relating to a patient or group of patients or any and all
other information which is of a confidential or proprietary nature (“Confidential
Information”);

(ii) use Confidential Information for Faculty course work only;

(iii) not disclose to any third party (except to his/her direct Faculty and Agency
supervisors, as required) any Confidential Information; and

(iv) not disseminate, publish, present or copyright any Confidential Information or

reports based on Confidential Information without the prior express written
permission of the owner or custodian of the Confidential Information;

(c) that he/she shall return to the Agency at the termination of the Practicum any and all
records, equipment or other property of the Agency, its staff and patients, made
available to him/her during the Practicum, in the same condition as when received by
him/her, reasonable wear and tear excepted;

(d) that he/she shall adhere at all times to the rules and regulations of the Agency as
disclosed by the Agency and/or the University, as the same may be revised from time
to time;
 (e) that he/she shall comply at all times with the policies of the University, as the same
may be amended. In the event he/she becomes aware of a conflict between such
policies and the Agency's rules and regulations, he/she shall immediately notify
his/her direct University supervisor and shall comply with supervisor's directions;

(f) that any intellectual property rights or interests that may arise during the course of the
Practicum shall be governed by the written polices of the University. Any such rights
or interests that the undersigned may develop or acquire during the course of the
Practicum, may be granted by the undersigned to the University for purposes of the
Practicum, and for internal educational or research purposes.; and

(g) that one of the terms of agreement between the University and the Agency is that the
University has agreed to take all precautions necessary or expedient to ensure that
Nursing Students are in good health at all times and able to perform the duties
assigned while on the premises of the Agency in accordance with the Agency’s
policies affecting direct caregivers;

The undersigned acknowledges that violation of this undertaking may result in action
respecting student status by the University or in other action over which the Faculty may or
may not have any control.

Dated at Calgary, Alberta, this _________________________, 20_____.

Louise Navor
_________________________________ _________________________________
Print Name Student Signature

30179710
_________________________________
University ID Number

UNDERGRAD/FORMS – All Programs

Schedule B – Acknowledgement and Undertaking
August 2017
 Identified Purposes and Handling of
Personal Information and
Personal Health Information in HSPnet
Updated: November 1, 2021

Background
The Health Sciences Placement Network (HSPnet) is a secure web-based system that is used by several provinces in Canada. The HSPnet system contains information about
students in clinical placements within health agencies and other placement sites. Students authorize their educational program to use and disclose their Personal Information (name,
student profile) and to use (but not disclose) their Personal Health Information via HSPnet for the purpose of locating and coordinating placements as required for their educational
program. This document provides a summary of the national HSPnet Policies relating to the protection of student information within HSPnet. The full Policies can be viewed on the
HSPnet website at www.hspcanada.net.

Collection, Use, and Disclosure of Personal Information and Personal Health Information in HSPnet
HSPnet policies ensure that Personal Information and Personal Health Information in HSPnet:

 Are collected, used, and disclosed only for purposes consistent with identifying and coordinating a student’s clinical placements;
 Cannot be used or disclosed without the consent of the student whose Personal Information or Personal Health Information is to be collected; and
 Are used by or disclosed on need-to-know basis only, and accessed by those involved in student placements from an educational program or placement site. Personal Health
Information is not disclosed to users outside of the student’s educational program except where there is a statutory obligation (required by law) to collect and disclose the
information (e.g., disease notification requirements or a Public Health Order).

Uses of Personal Information

Personal Information Collected Disclosure of Personal Information
BY authorized users in the student’s
May include any or all of: TO authorized users at the placement site
educational program
 Student name  To contact students regarding Student name is disclosed after a placement is accepted by the site and
confirmed by the educational program, to facilitate arrangements (such as
 Student home address, phone numbers, email placement needs or status, or
orientation and preceptor assignment) and as a record of placements. Name
addresses regarding urgent issues such as
may be disclosed prior to acceptance if the site has a reasonable justification
 Student number labour disruption at the placement (e.g. to arrange a student interview).
destination
 Student photograph
 Placement Preferences (1st, 2nd and 3rd choices  To generate class placement lists, Student email address (issued by the educational program) may be released
confirmation notices and schedules to support administration of computer access at the site.
if offered)
 To maintain a student history of
 Student gender Student certification ID may be released to sites if needed to coordinate
placements
 Student certification ID with registering body for placement arrangements such as computer access.
their discipline (e.g. RN Association, College of
Student gender may be disclosed in the following limited situations:
Physicians and Surgeons)
 For allocation of change rooms and lockers at the site
 Date of Birth: DD/MM (excludes year)
 For matching the gender of the student and supervisor (e.g. for homecare
visits where the client may specify a preference)

Date of Birth (DD/MM) may be released to sites if needed to coordinate

placement arrangements such as computer access.
Identified Purposes and Handling of Personal Information in HSPnet Page 2
Updated: July 9, 2019

Student prerequisite status as required by To track student compliance with each Not disclosed except where there is a statutory obligation.
placement sites (e.g. criminal records check, CPR site’s published requirements for criminal
or other certifications) records check, CPR certification, etc.
Student profile of educational or work history To facilitate a good fit between the student and the placement Site, learning experiences offered, and
relevant to placement requests supervisor/preceptor to be assigned.

Uses of Personal Health

Personal Health Information Collected Information Disclosure of Personal Health Information
May include any or all of: BY authorized users in the student’s TO authorized users at the placement site
educational program
Status of compliance with site requirements for To track status of a student’s eligibility Not disclosed except where there is a statutory obligation.
safety and/or infection control: according to the requirements of
placement sites.
 Information on a student’s immunity or
immunization status for vaccine-preventable
diseases such as Varicella, Diphtheria /
Tetanus, Influenza, and Measles/Mumps or
Rubella
 Information on Tuberculosis status including TB
test and/or chest X-ray results

Safeguards
 The accuracy and completeness of personal information within HSPnet is maintained through the use of system tools such as mandatory fields and formatting rules, and through
periodic reviews of data quality to identify the need for interventions such as user training or system modifications.

 HSPnet data is physically and logically secured in accordance with industry standards and best practices, including enforcement of strict rules for physical security and backups,
password protection at all points of access, and use of anti-virus software, firewall protection, and data encryption.
 Periodic audits of HSPnet transactions are carried out to ensure there are no problems and/or gaps in the user interface that might permit inappropriate access to or update of
data.

 Personal information on each student, along with their placement history, is retained until the student’s completion of or withdrawal from the educational program as recorded on
their HSPnet profile, or after the consent expiry period of six years, whichever occurs first. A copy of their Personal Information is available to a student upon request to their
jurisdiction’s Privacy Officer or the national HSPnet Privacy Officer.

Openness, Access, and Challenging Compliance

 An individual can access their own information as well as a complete description of the type of Personal Information or Personal Health Information used/disclosed and the
purposes for using or disclosing the information. Such requests can be made in writing by the student to the national HSPnet Privacy Officer and/or to the local Privacy Officer
within the student’s jurisdiction (contact information for each province or jurisdiction is available on the HSPnet website at https://hspcanada.net/privacy-officers/ ).
 An individual may request changes to their Personal Information or Personal Health Information contained in HSPnet, or may register a complaint or challenge regarding the
handling of their information in HSPnet, by submitting a request in writing to the national HSPnet Privacy Officer or local Privacy Officer within their jurisdiction.
 Consent Form for Use and Disclosure of Student Information
Student Number: 30179710 Educational Program: Nursing
First Name: Louise Middle Initial: J Last Name: Navor
1. Permission to Use and Disclose Your Student Related Personal Information and Personal Health Information

By signing this consent, you authorize your educational Program (Bachelor of Nursing) to:

• Collect, use and/or disclose your personal information (name and student profile information that is under the custody and
control of your Program) to authorized staff of Receiving Agencies for the purpose of locating and coordinating an appropriate
placement experience (e.g. clinical practica, fieldwork, or preceptorship) as required by your educational program;
• Use your student related personal information and personal health information relating to placement prerequisites, for the
purpose of tracking your compliance against Receiving Agency safety and infection control prerequisites for accepting
students. Placement prerequisites that may be tracked include personal information such as CPR certification or criminal
records check status, and personal health information such as immunity/immunization status of vaccine-preventable
diseases. Placement prerequisite information is used only by staff involved with your educational program, and is never
disclosed to users external to your educational program.
• Disclose your personal information to the owner and administrator of the HSPnet system, namely Provincial Health Services
Authority British Columbia (PHSA), to allow PHSA to indirectly collect your personal information to provide HSPnet student
placement services.

2. Consent Period

This consent is effective immediately and shall remain valid for up to six years, or shall be voided upon your completion of the
Program, your formal withdrawal from the Program, or upon written request as described below.

3. Your Rights With Respect to This Consent

3.1 Right to Refuse Consent - You have the right to refuse to sign this consent, and if you refuse your placement will be
processed manually at the earliest convenience of the Program and Receiving Agency.
3.2 Right to Review Privacy & Security Policies - A copy of the document entitled Identified Purposes and Handling of
Personal Information in HSPnet, which summarizes Privacy and Security policies relating to how we may use and disclose
your personal information via HSPnet, is distributed with this Consent Form. You may wish to review the complete Privacy
and Security Policies for HSPnet before signing this consent. The Privacy and Security policies may be amended from time to
time, and you can obtain an updated copy by contacting [email protected].

3.3 Right to Request Restrictions on Use/Disclosure - You have the right to request that we restrict how we use and/or
disclose your personal information or personal health information via HSPnet for the purpose of locating and coordinating a
suitable placement experience. Such requests must be made in writing to the placement coordinator for your Program. If
we agree to a restriction you have requested, we must restrict our use and/or disclosure of your personal information in the
manner described in your request. If this restriction precludes our ability to coordinate your placement via HSPnet, then
your placement will be processed manually at the earliest convenience of the placement coordinator and receiving agency.

3.4 Right to Revoke Consent - You have the right to revoke this consent at any time. Your revocation of this consent must be
in writing to the placement coordinator for your Program. Note that your revocation of this consent, or the voiding of this
consent upon your completion or withdrawal from the Program, would not be retroactive and would not affect uses or
disclosures we have already made according to your prior consent.

3.5 Right to Receive a Copy of This Consent Form - You may request a copy of your signed consent form.
Collection of your personal information is done under the authority of the privacy legislation that applies to educational institutions
in your province. For more information visit www.hspcanada.net/privacy-and-security/.

I hereby authorize my educational Program to use and/or disclose my personal information via HSPnet for the purpose of
locating and coordinating appropriate student placement(s) as required by the curriculum.

/ /
Signature of Student Date MMM / DD / YYYY

Student Consent Basic - Form A - Revised: June 9, 2020