Acknowledgment of Criminal Record Check Form by hkw27409


									                                            Acknowledgment of Criminal Record Check

I, ________________________ (Please print name), being a student enrolled in the

undergraduate education nursing program at the University of Saskatchewan, College

of Nursing, hereby acknowledge that I have completed and submitted a Criminal Record

Check request, including a request for a Vulnerable Sector Search, to the appropriate


Date CRC request submitted to Police Department or RCMP:


I agree to retain the original copy of the results of the CRC and will provide this

information to clinical agencies at their request. I further agree to report criminal

convictions and/or outstanding charges that occur after the date of the original CRC to

the College of Nursing Associate Dean at your site, and understand that failure to report

convictions and charges will be grounds for disciplinary action.

______________________________                            ___________________
Student Signature                                         Date

______________________________                            ___________________
Witness Signature                                         Date

Witness (Please print name)

Please submit this form to the Clinical Placement Coordinator at your site prior to the start
of 400 level clinical courses.

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