FORM B

Externship Host Application Form, 2010-2011 1. HOST INFORMATION Name: Naturopathic College of

Graduation

Address: License #: Tel:/Fax:

Jurisdiction of License:

Email: Number of years you have been in practice: ________________ (A minimum of 3 yrs is required.) I carry full Professional Liability Insurance through the CAND: Yes No I carry full Professional Liability Insurance through the OAND: Yes No (Our student liability insurance is only available through the OAND/CAND insurance carriers. We are not able to accept hosts with alternate insurance carriers.) Name of Student you wish to Host:__________________________________________________ Please indicate which Externship period you are applying for: August 2010 month-long Externship November 2010 month-long Externship February 2011 month-long Externship September – December 2010 Weekly Externship January – April 2011 Weekly Externship May - August 2011 Weekly Externship (not available to students in their first clinic term)

8/13/2010 KBT 1

FORM B

2. PRACTICE DESCRIPTION Name of Practice: ___________________________________________ The externship host site is an insured facility: Yes No (Required for participation in Externship Program.) Number of Clinical Staff at this location:

ND_____ MD_____ DC_____ RN_____ RMT_____ Other_____ Number or patients seen by you each week: __________ Types of therapies you utilize:

Acupuncture Botanical Counselling Physical Medicine High Velocity Manipulation Homeopathy Hydrotherapy Nutrition Other

____________________________________________________

3. LABORATORY FACILITIES

Please describe procedures performed on-site and those referred to outside facilities. Indicate if most labwork is performed on-site or referred. ________________________________________________________________________________

_______________________________________________________________________________

4. DIAGNOSTIC AND THERAPEUTIC EQUIPMENT

Please describe diagnostic and therapeutic equipment utilized in your facility (i.e. microscopy wet mounts, ultrasound/EMS, hydrotherapy, etc.) _______________________________________________________________________________

______________________________________________________________________________

5. DISPENSARY

Please describe the type of dispensary (i.e. small/limited, comprehensive, etc) at your facility and the type of items stocked (i.e. botanicals, TCM patent formulas, homeopathics, etc.) _______________________________________________________________________________

_______________________________________________________________________________

6. SUPERVISION

a) Please describe the level of supervision that the intern will receive (i.e. I will be present for the entire patient visit; OR I will be present for part of the patient visit, etc.) _______________________________________________________________________________________________

_______________________________________________________________________________________________

b) You are expected to conduct a brief review of the day’s cases at the end of the day. Please

describe how you anticipate fulfilling this requirement.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

8/13/2010 KBT 2

FORM B

7. CLINICAL ACTIVITIES

Please indicate which areas the intern will be able to participate with a high degree of independence, some degree of independence, or no independence: Degree of Independence

High Some Little/No Full patient visits with new patients Full patient visits with follow-up patients Physical examinations Intake interviews Laboratory tests i.e. analysis of blood, urine, stool, hair, etc. Formulation of diagnosis Formulation of Treatment Plan Homeopathic Case Taking Hydrotherapy Homeopathic prescribing Compounding and dispensing of botanical medicines Botanical medicine prescribing Nutritional prescribing/counselling Physical medicine such as ultrasound and interferential current TCM patent prescribing Training and use of specialized technology/modalities Administrative duties including reports or findings, scheduling, referral letters, medico-legal reports, insurance reports. Other (please list)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

8/13/2010 KBT 3

FORM B

Responsibilities & Standards for the Externship Placement THE EXTERNSHIP HOST WILL: Ensure a safe working environment for the student and provide proof of appropriate facility insurance if

asked. Ensure that a licensed/registered ND is on the premises at all times while the student is working and/or

training on site. Ensure that at a minimum the student will be supervised indirectly for procedures listed in Table A

below and directly for procedures listed in Table B below. Co-sign all patient charts, thereby accepting legal liability for cases seen by the student intern. Ensure that the CCNM Primary Intern Competencies Evaluation Form 2010-11 is completed and

submitted to the Office of Academic Affairs no later than 2 weeks following the completion of the externship placement.

This form will be sent to you as part of an information package upon approval of this application.

Ensure that any Case Management Forms the student submits to you for marking are submitted to the Office of Academic Affairs no later than 2 weeks following the completion of the externship placement.

Information in regards to these forms will be sent to you as part of an information package upon approval of this application.

THE STUDENT WILL: Exhibit exemplary personal and professional conduct and behaviour at all times as a representative of

the Canadian College of Naturopathic Medicine. Purchase Student Errors and Omissions Liability insurance covering them for the duration of their

externship placement. The student is responsible for submitting a copy of this to the externship host. Carry with them all personal medical equipment. Ensure that all medical activities are within the scope of practice designated for the province in which

the Externship is taking place. Ensure at a minimum they have indirect supervision for procedures in Table A below and direct

supervision for procedures in Table B below. Understand that they are required to meet all regular course deadlines, i.e. an externship

placement does not entitle them to deadline extensions for course requirements. CLE450 Requirements The Externship placement may fulfill up to a maximum of 10% of the total clinic hour requirements (103 hours) , 20% of total patient visit requirements (52 patient visits) and 20% of the modality requirements for CLE450. Hours completed in excess of 103 may be claimed as preceptoring hours.

8/13/2010 KBT 4

FORM B

TABLE A

INDIRECT SUPERVISION required, i.e. the supervisor must be on premises and visit the intern for a period of time, for the following: Full patient visits with new patients History intake Full or partial physical examinations Training and use of specialized technology/modalities Medical lab tests (excluding blood draws) Formulation of diagnosis Soft tissue manipulation (naturopathic bodywork/other) Hydrotherapy Homeopathic case taking and prescribing Botanical prescribing, compounding and dispensing Nutritional assessment and prescription. Physical medicine such as ultrasound and interferrential current Traditional Chinese/Asian Medicine, Acupuncture (marking of points) Medical administrative duties including reports of findings; scheduling; referral letters; medico-legal

reports; insurance reports

TABLE B

DIRECT SUPERVISION required, i.e. the supervisor must be present in the interview room during the entire procedure for the following: Acupuncture needle insertion High velocity low amplitude thrust (spinal manipulation) Blood draw Breast examination Female pelvic examination and PAP test Examination of male or female genitalia Prostate examination Anoscopic examination Injection therapy of any kind

8/13/2010 KBT 5

FORM B

8/13/2010 KBT 6

Host Criteria The following criteria will be used to assess eligibility for participation in the Externship Program. The host ND must be a graduate of an accredited CNME institution and currently licensed in their

jurisdiction of practice. The host ND has been in practice for a minimum of three years and sees a minimum of 25 patients per

week. The host ND has professional liability insurance with the CAND or OAND. The externship host site is an insured facility. The intern can be given a high degree of autonomy during the placement, while still being

appropriately supervised as outlined below in Tables A and B. I agree to adhere and abide by all terms and conditions of CCNM’s Externship Program. __________________________________________ Date: _________________________ ND Host Signature Please submit with this application:

A copy of your professional liability insurance A copy of your most recent registration/license renewal

Please return this document by fax or mail, by the following deadlines:

August Month Externship: June 30, 2010 September – December Weekly Externship: June 30, 2010 November Month Externship: Sept. 15, 2010 January – April Weekly Externship: November 15, 2010 February Month Externship: November 15, 2010 May – August Weekly Externship: March 15, 2011

(not available to students in their first clinic term, i.e. CLE350)

Office of Academic Affairs, ATTN: Externship Program Canadian College of Naturopathic Medicine 1255 Sheppard Ave. E. Toronto, ON M2K 1E2 Fax: 416-498-9763

The Dean and Associate Dean for Clinical Education will determine whether your application meets the criteria for an Externship placement site. The Office of Academic Affairs will notify you of the decision.

DECISION: _______________________________ _________________________________________ Date: ___________________________ Associate Dean Clinical Education _________________________________________ Date: ___________________________ Dean