Interprofessional Education Activity Approval Form

Interprofessional Education Activity Application Form

Please complete this form to have your interprofessional learning activity added to theInterprofessional Education (IPE) Passport and assigned an IPE point value.

NAME OF ACTIVITY

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CONTACT INFORMATION

Activity Lead/Primary Contact

Email

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Program

Date of Application

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Faculty Support Contact (If student-led activity)

Faculty Email

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Provide as much information as possible. The College of Health Disciplines will use this information to determine your activity’s eligibility for the Interprofessional Education Passport. Once your activity has been approved, it will be assigned a point value indicating the depth of interprofessional learning and classified as exposure or immersion, based on a standardized rubric (see companion document).

Please return this form to:

If you have any questions or would like to schedule a consultation to get support completing this form, please email our Education Program Coordinator:

PROFESSIONS INVOLVED (STUDENTS)

☐Audiology

☐Counselling Psychology

☐Dental Hygiene

☐Dentistry

☐Dietetics

☐Genetic Counseling

☐Nursing

☐Occupational Therapy

☐Physical Therapy

☐Speech Language Pathology

☐Medicine

☐Midwifery

☐Pharmacy

☐Social Work

☐Other:

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How many students can attend this event? Click here to enter text.

Are there any discipline limitations for this event? (Ex. Only 5 students from each selected discipline) Click here to enter text.

DESCRIPTION OF THE ACTIVITY(Max. 300 words)

Please include website links if this activity is being marketed online.

LENGTH OF ACTIVITY AND DELIVERY

Please include dates, times, location

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MODE OF DELIVERY

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LEARNING OBJECTIVES AND ASSESSMENT

Provide a clear, written description of what interprofessional skills and knowledge learners should have by the end of the learning experience. These should be appropriate given the stage of student development and be assessed. You should have a plan to communicate these learning objectives to the students.

Choose from the example objectives below or list those you develop yourself. For all selected learning objectives, please specify how students will accomplish each over the duration of the activity. For help developing learning objectives, refer to the accompanying Interprofessional Learning Objective Development Tool.

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ASSESSMENT

Indicate how you will assess student learning.

☐No Assessment

☐Individual or group presentations

☐Case-based essays or care plans

☐Portfolios

☐Self-Assessment

☐Peer-Assessment

☐Examinations

☐Reflective Journal

☐Assignment

☐Other:

ADDITIONAL INFORMATION RELATING TO ASSESSMENT OF THE LEARNER

In addition to the assessment strategies that you have selected above, please provide further details on your assessment processes such as where/how the assessments takes place; who provides the assessments; and how learners will receive feedback. If students are required to complete a written assessment (case-based essay or care plan, portfolio, self-assessment, peer assessment, reflective journal, assignment, etc.) please attachan electronic copy of the assessment outline when you submit you Activity Application form.

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FACILITATION

Number of and profession of facilitators and their role

Have faculty/facilitators had any prior IPE education? Please specify (e.g. workshops, courses, session preparation)

Will a session debrief take place? In what form will it occur?If a session debrief will take place, please list the debrief questions and items for discussion below.

EVALUATION OF THE ACTIVITY

Please attach any supporting documents or links.

Provide details about the evaluation of the activity (e.g. follow-up survey, focus group). Please include all follow-up questions or activities students may complete.

Please provide details on the sustainability of the session (can this activity be repeated in future academic years?)

ACTIVITY DOCUMENTS

Please send an electronic copy of any materials that may be shared with students to the Passport Administrator with your Activity Application. This includes marketing materials (flyers, brochures, posters, etc.) and activity handouts.

GLOSSARY

Competency

A complex ‘know act’ that encompasses the ongoing development of an integrated set of knowledge, skills, attitudes, and judgments enabling one to effectively perform the activities required in a given occupation or function to the standards expected in knowing how to be in various and complex environments and situations (CIHC 2010). Found at

Competency domain

An interacting grouping of activities that comprise part of a whole (CIHC 2010). Found at

Competency statement

A strong overarching statement that guides behaviour and that lasts over long periods of time (CIHC 2010). Found at

Collaborative Patient-Centred Practice

Promotes the active participation of each health care discipline in patient care. It enhances patient and family-centred goals and values, provides mechanisms for continuous communication among caregivers, optimizes staff participation in clinical decision-making within and across disciplines and fosters respect for disciplinary contributions made by all professionals. (Health Canada 2003). Found at

Collaborative Practice

An interprofessional process for communication and decision making that enables the knowledge and skills of care providers to synergistically influence the client/patient care provided. (Way, Jones, & Busing 2000) Collaborative practice is interlinked to the concept of teamwork. Found at

Profession

An occupation, vocation or career requiring special training (for example, doctor, licensed practical nurse, respiratory therapist, air traffic controller, lawyer, accountant). Found at

Teamwork

Describes an interdependent relationship that exists between members of a team. It is an application of collaboration. “Collaboration” deals with the type of relationships and interactions that take place between coworkers. Effective health care teamwork applies to caregivers who practice collaboration within their work settings. (D’Amour, Ferrada-Videla & San Martin Rodriguez 2005). Found at

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