Internship Change Form

CHANGES TO PROSTHETIC/ORTHOTIC INTERNSHIP
Change Requested (select all that apply)	Place of Employment (complete section A, B and C) Supervisor (Complete section A and C)
SECTION A:
INTERN
First Name *Enter your First Name
Last Name *Enter your Last Name
Email Address *
Phone #
SECTION B:

NEW PLACE OF EMPLOYMENT:

Company / Location:
Address
City
Province
Postal Code
Contact Phone #
Fax #
Contact email:
Commencement date: (mm/dd/yr)
PREVIOUS PLACE OF EMPLOYMENT:

Company or Location:
Work Address
Work City
Work Province
Work Postal Code
Work Phone #
Work Fax # (xxx)xxx-xxxx
Last Day Worked (mm/dd/yr)
Employment email
INTERNING IN:	Prosthetics Orthotics Full-Time Part-Time
SECTION C:

1.	PRIMARY SUPERVISOR (P.S.)
(P.S.) First Name
(P.S.) Last Name
(P.S.) C.B.C.P.O. Reg. #
(P.S). Name of Facility
(P.S.) Effective Date (mm/dd/yr)
2.	SECONDARY SUPERVISOR (S.S.)
(S.S.) First Name
(S.S.) Last Name
(S.S.) C.B.C.P.O. Reg. #
(S.S). Name of Facility
(S.S.) Effective Date (mm/dd/yr)
SUPERVISOR(S):
As the Intern's Supervisor, you will be responsible for ensuring that the Intern is prepared for the Registration Examination. The Resident must be working his/her Internship hours in the appropriate discipline, under your direct supervision as stipulated by Orthotics Prosthetics Canada (OPC). During scheduled unsupervised hours, the Intern must not conduct themselves in any way contrary to the OPC Canons of Ethical Conduct.
Removal:	REMOVAL OF SUPERVISOR(S)
Name:
C.B.C.P.O. Reg. #:
Effective Date (mm/dd/yr):
Name
C.B.C.P.O. Reg. #
Effective Date (mm/dd/yr)
Effective Date:
Signature Form
Please download the Internship Change Signature Form, fill and upload in the next field:
Signature Form Upload:

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