Preceptorship Contract – Student Preceptorship Contract - Student 11203 70 Street NW Edmonton, AB T5B 1T1 registration@theccoa.ca Preceptorship Application and Contract between the College of Chiropractors of Alberta (CCOA) and the Chiropractic Student Date(Required) DD slash MM slash YYYY Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Phone(Required)Name of student's college:(Required)Preceptorship start date:(Required)Preceptorship end date:(Required)CCOA member:(Required) CCOA Agreement CCOA Agreement I hereby agree to abide by the following directions set by the CCOA. I understand that this contract can be cancelled at any time by the CCOA. I understand that it is my responsibility to ensure that I have professional liability insurance valid in Alberta, Canada through my College of attendance for acts performed under this agreement in Alberta. I have enclosed a cheque or money order for $100 payable to the College of Chiropractors of Alberta. I further understand that all the procedures I perform at the chiropractor’s office must be verified and supervised by the chiropractor. (Supervision meaning that the chiropractor will be physically present and available to assist). I also agree that written consent will be obtained from any patient I will treat. I agree that with supervision I can perform the following procedures: Obtain information for a patient entry Obtain a case history Conduct an examination, including a diagnosis that must be confirmed Use a deliberate, brief, fast thrust to move the joints of the spine beyond the normal range but within the anatomical range of motion, which generally results in an audible click or pop Insert or remove instruments, devices or fingers beyond the cartilaginous portion of the ear canal Insert or remove instruments, devices or fingers beyond the point in the nasal passages where they normally narrow and beyond the anal verge Reduce a dislocation of a joint Order any form of ionizing radiation in medical radiography, and nuclear medicine Apply any form of ionizing radiation in medical radiography Order non-ionizing radiation in magnetic resonance imaging, and ultrasound imaging Assist in rendering treatment for ultrasound, electro therapy, massage or trigger point therapy Student Signature(Required)Date Signed(Required) DD slash MM slash YYYY Witness Signature(Required)Date Signed(Required) DD slash MM slash YYYY Questions? Please feel free to contact registration@theccoa.ca.
