Consent form to permit your educational institution to use and

Consent form to permit your educational institution to use and disclose some personal information,
with the help of the web-enabled application HSPnet, to the agencies receiving you for an internship
Please provide the information in capital letters
Student name: _____________________________________________ Student number: __________
Educational program: ___________________________________
Group number: ___________
I confirm that I have reviewed and understand the information contained in this consent form relating to
the use of my personal information and the disclosure of my name for placements through the use of webenabled application HSPnet.
I also understand that my personal information will be used only by my educational institution and by the
agencies which confirm my placements via the HSPnet web-enabled application.
I consent to the use and disclosure of my personal information for the sole purpose of identifying and
coordinating a placement through the use of web-enabled application HSPnet in accordance with the
terms and conditions contained in this consent form.
Signed in (CITY) ________________________________________Quebec, on (date) ______________
Signature of student____________________________________________________
(Signature of the parent or guardian if under the age of 18) 1. Introduction
McGill University, Ingram School of Nursing requires your consent in order to use your personal
information for the sole purpose of finding and coordinating an appropriate placement as required by
your educational program, through the use of the web-enabled application HSPnet.
2. Use of your Personal Information
This consent form will authorize McGill University, Ingram School of Nursing to use your personal
information within the HSPnet web-enabled application in order to:
best meet your placement needs while considering the desired learning experiences;
communicate with you, when required, regarding your preferences, the status of your placement
or in the event of an emergency (e.g. placement cancellation);
ensure compliance with the placement prerequisites and guidelines published by each receiving
agency (e.g. vaccinations, CPR certification);
ensure the management of your clinical placements requests.
Only the personal information required to meet placement prerequisites and to ensure the
management of your placement file will be used within HSPnet. Based on the requirements of a
receiving agency or of a placement destination, the personal information collected by your educational
institution may include:
your contact details;
your gender;
a list of your previous placements;
Consent form – Student placement management, 3 septembre 2013 1/2 
CPR certification;
your immunity/immunization status of vaccine-preventable diseases;
certificate of good conduct;
any other information related to placement prerequisites (e.g. OIIQ student certificate, car
ownership, languages spoken, Permanent code (PC) issued by the Ministère de l'Éducation,
du Loisir et du Sport (MELS), etc.).
The personal information collected within the web-enabled application HSPnet becomes part of your
file and will not be used for any other purpose. This information will be used only by staff working
in your educational program and will never be disclosed to persons outside the program.
We invite you to familiarize yourself with the policies relating to the protection and security of personal
information within the management framework of your placements through the HSPnet web-enabled
application. Since these policies are subject to change, we recommend that you consult the latest
version of this document by visiting the following Internet site:
3. Disclosure of Information to Receiving Agencies
McGill University, Ingram School of Nursing will release your last name and first name, through the
HSPnet web-enabled application to the receiving agency. Your gender, as indicated on your student
record, for locker assignment and your MELS Permanent Code for user account set-ups will also be
sent to receiving agencies that require this information. Receiving agencies will not receive any of the
above mentioned personal information until your placement is confirmed.
4. Security Measures
Your data constitutes “personal information” under the privacy legislation and mechanisms are in
place to protect their confidentiality. All information and communications involving the use of the
HSPnet web-enabled application are therefore physically and logically safeguarded in accordance
with industry standards and best practices. Only persons who are mandated to carry out the
management of your placements will have access to your data through the HSPnet web-enabled
5. Consent Period
This consent is effective immediately and shall remain valid for 180 days following the completion of
your study program (for up to six years). This consent shall be voided in the event of your withdrawal
from the program or upon your written request (see item 6).
6. Right of Access, to request a modification in your personal information
Upon your written consent to your educational institution (to the attention of your Placement
Coordinator), you are entitled: to gain access to the information collected in your file within the HSPnet
web-enabled application, to request a rectification in your personal information or to withdraw your
consent. Your request will be processed within 30 days of receipt.
7. Right to Refuse Consent
You have the right to refuse to sign this consent form. In this event, your file and your placement
requests shall be processed without your name, using the HSPnet web-enabled application.
8. Consent
Collection of your personal information is done under the authority of the privacy legislation that
applies to educational institutions in Quebec. For more information, please visit:
You can request a copy of the signed consent form. Consent form – Student placement management, 3 septembre 2013 2/2