IPAC-SWO IPAC Education and CIC/LTC-CIP Funding

Before submitting an application, review the IPAC-SWO Educational Funding terms and conditions and submission instructions. All sections of the application must be completed. Where there is no information to be provided, state "Not Applicable"

Applicant Information

First Name*

Last Name*

Academic Designation/Credentials

Facility Name/Organization

Address*

Phone*

Email Address*

Number of years in Infection Control*

IPAC Canada Membership Number

IPAC SWO Chapter Member (confirmation of membership will be validated with current IPAC SWO member list)*

Yes

No

I don't know

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Application for Award

Which award are you applying for?

IPAC Course

CIC Initial Certification

CIC recertification

LTC-CIP

If you chose IPAC Course

Select IPAC Canada sponsored, acknowledged or endorsed course that was successfully completed

IPAC Canada: Online Essentials in Infection Prevention and Control Course

Centennial College: Preventing and Controlling Infections in Non-Acute Care Settings

Centennial College Onsite and Online Infection Control Course

Queen's University Infection Prevention & Control Online Professional Development Course

University of BC Infection Prevention and Control Certificate

Bay River College Infection Prevention and Control Program

Date of successful course completion

Course Registration Fee

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If you chose CIC/LTC-CIP Initial Certification

Examination date

Exam registration fee USD

Amount Paid CAD

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If you Chose CIC Recertification

Date of CIC recertification

Recertification fee USD

Amount paid CAD

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Attestations

I confirm that I have not received funding from other sources for this educational course/CIC/LTC-CIP certification or recertification (e.g. employer, IPAC Canada CIC certification award, other IPAC chapter)

Yes

No

I confirm that, if chosen for this award, I will immediately notify my employer and will not apply or accept additional reimbursement of certification examination expenses (e.g. IPAC Canada CIC Award)

Yes

No

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I attest that I have been truthful in all responses to questions contained in this application.

Signature/name

Date

I give permission for IPAC SWO to publish my name and photograph on the IPAC SWO Chapter website or on Chapter communications/reports

Name only

Photograph only

Name and photograph

I do not give permission to publish my name or photograph

Proof of successful course completion/CIC/LTC-CIP certification or recertification and receipt for course/certification fees is required to be submitted with this application to be considered for an award.  

Upload proof of successful completion of IPAC Canada sponsored, acknowledged and endorsed course

 

Upload receipt for course registration fee

 

Upload proof of CIC/LTC-CIP certification or recertification

 

Upload receipt of CBIC certification or recertification fee

 

Upload Proof of Canadian funds paid (applicable for CBIC certification or recertification only)

 

Enter the code displayed*