Facilitator in Chemotherapy Application Form 2024

Standardized Chemotherapy and Biotherapy Expert Facilitator Course Application Form 2024
*** Deadline: 1 weeks before the start of course***

Name Name First Last
Work Title/Position
Years of Oncology Nursing Experience
Organization's Name
de Souza username (email address you use to access de Souza websites)

Please assist us in verifying your identity against our database by providing your de Souza username.
Alternate Email
Nursing Education Background (Indicate all degrees obtained):

Nursing Education Background (Indicate all degrees obtained): RN (diploma) RN (degree) Master's Prepared RN extended class APN PhD

Indicate all degrees obtained
College of Nurses of Ontario Registration Number
Years of experience administering chemotherapy and/or biotherapy
Average estimated frequency of administering chemotherapy and /or biotherapy in the last 2 years

Enter number per week.
Years of experience teaching chemotherapy and biotherapy

Enter the number of years. To indicate no experience, please enter 0.
Average number of courses taught each year

Please enter a numerical character indicating the number of courses taught each year.
Name (First, Last) of the Nursing Supervisor/Consultant in your organization

Please enter the full name.
Please provide the completed form along with the following:
Date of Provincial Standardized Chemotherapy and Biotherapy course completion

Enter the date of when you successfully completed de Souza Institute's Provincial Standardized Chemotherapy and Biotherapy course.
Resume or Curriculum Vitae (3 pages maximum)

Attach Files
Copy of your current College of Nurses of Ontario (CNO) Registration

Attach Files
Proof of Certification in Oncology Nursing Canada (CON(C)) or the Oncology Nursing Certification (OCN)

Attach Files
Letter of support from Supervisor/ organization leader for your becomnig a facilitator

Attach Files
By clicking Continue below I confirm that the information provided in this application is complete and accurate.
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Facilitator in Chemotherapy Application Form 2024

Facilitator in Chemotherapy Application Form 2024

Please provide the completed form along with the following:

By clicking Continue below I confirm that the information provided in this application is complete and accurate.

____________________________________________________________________