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 authorities. 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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