Rady Faculty of Health Sciences policies

Guideline name	Prevention of learner mistreatment
Application and scope	Faculty, staff and learners of the Rady Faculty of Health Sciences and its Colleges

1. PURPOSE

The purpose of these Guidelines is to:

(a) Acknowledge the importance of a safe learning environment for all. Mistreatment of learners has negative consequences for learner well-being and functioning of teams. Learner Mistreatment truncates learning and impacts patient safety. These Guidelines strive to create an environment free of mistreatment where learners feel safe to report.

(b) Define Learner Mistreatment in any learning environment, including without limitation academic learning environments and clinical learning environments.

(c) To set out clear mechanisms and procedures for learners to report mistreatment against them, or mistreatment that learners observe against others, without fear of retaliation.

(d) Ensure compliance with relevant accreditation standards applicable to the educational programs offered by the Rady Faculty of Health Sciences (“RFHS”) and its Colleges.

(e) Be aligned with existing policies at the University of Manitoba. These Guidelines are meant to be consistent and compliant with existing University of Manitoba policies and bylaws. Where any portion of these Guidelines conflict with these University policies/bylaws, the latter will govern.

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2. DEFINITIONS

2.1 The terms in this Definition section are defined for the purposes of these Guidelines.

“Academic Staff” refers to all individuals whose primary assignment is instruction, research, and/or service/academic administration. This includes employees who hold an academic rank such as professor, associate professor, assistant professor, instructor, lecturer, librarian, or the equivalent of any of those academic ranks. The category also includes a dean, director, associate dean, assistant dean, chair or head of department, visiting scholars, senior scholars, and those holding unpaid academic appointments, insofar as they perform instructional, research, and/or service/academic administrative duties. This includes non-unionized academic staff of the Colleges or the Rady Faculty of Health Sciences, visiting professors, clinicians with academic appointments and including academic staff whose salary or stipend may be paid, in whole or in part, by another organization.

“Colleges” mean the Dr. Gerald Niznick College of Dentistry, the School of Dental Hygiene (SDH), the Max Rady College of Medicine, the College of Nursing, the College of Pharmacy and the College of Rehabilitation Sciences.

“IHP” means the Interdisciplinary Health Program (IHP) of the Rady Faculty of Health Sciences, offered in partnership with the Faculties of Arts and Science, offering two four-year degree programs: the Bachelor of Health Sciences and the Bachelor of Health Studies.

“Learner” means an individual registered, enrolled, or classified as a student, resident, trainee or fellow within or with the University of Manitoba, participating in any of the College programs or Rady Faculty of Health Sciences programs, including the IHP.

“Confidential” means the University’s obligation to handle personal information and personal health information in accordance to The Freedom of Information and Protection of Privacy Act and The Personal Health Information Act.

“Complainant” means the individual or individuals bringing forward a report of mistreatment.

"Respondent" means an individual or individuals accused of having caused or contributed to mistreatment.

“Learner Mistreatment” means an intentional, or unintentional, disrespectful treatment occurring by any individual against a learner or colleague that has or may have the effect of creating an intimidating, humiliating, hostile or offensive work or learning environment for learners in that circumstance. It entails behavior that shows disrespect for the dignity of others and can take the form of physical or psychological punishment, harassment or discrimination.

Examples of mistreatment include, but are not limited to:

(a) Actions or criticism conducted in public that can be interpreted as embarrassing or humiliating.

(b) Verbally abusing, belittling, ridiculing or yelling at a learner in public or private.

(c) Speaking to a learner in a sarcastic or insulting manner.

(d) Subjecting the learner to racially or ethnically offensive remarks or names.

(e) Requiring a learner to perform personal services (i.e. babysitting, shopping).

(f) Pressuring learners to exceed established restrictions on work or duty hours.

(g) Not providing learners with clear learning/work expectations yet holding them responsible for the expectations.

(h) Directing learners to perform an unreasonable number of routine hospital or clinical procedures where performing those activities interferes with a learner’s attendance at educational activities, (e.g. rounds, classes).

(i) Disparaging the learner’s choice of residency, profession, or other career aspirations.

(j) Intentional physical contact such as pushing, shoving, slapping, hitting, tripping.

(k) Subjecting the learner to threatening gestures.

(l) Excluding a learner from reasonable learning opportunities.

(m) Using grades as punishment rather than as an objective evaluation of performance.

(n) Assigning duties as punishment rather than education.

(o) Threatening to fail, give lower grades, or give a poor evaluation for anything other than documented performance issues.

(p) Intentionally neglecting or excluding the learner from communications.

(q) Intentionally singling out a learner for arbitrary treatment that could be perceived as punitive.

Learner Mistreatment is not:

• A supervisor or manager to engage in the legitimate evaluation of the performance of an employee or contractor, or otherwise overseeing their work;

• Academic staff to engage in the academic evaluation of a learner’s work;

• A good faith and formal evaluation of an academic staff member or supervisor to be conducted;

• A legitimate peer review or other critique of research or academic work to be conducted;

• A unit head to take actions intended to address or deter violent, threatening, or intimidating behaviour, or behaviour which significantly disrupts the University and members of the University community.

"RFHS Community" means all Rady Faculty of Health Sciences members including Faculty/College/School Councils, employees, anyone holding an appointment with the Rady Faculty of Health Sciences, learners, volunteers, external parties conducting business within the RFHS, contractors and suppliers within the RFHS.

"RFHS Matter" means any activity, event, or undertaking in which a member of the RFHS community participates, which has a substantial connection to the RFHS, such as:

a) RFHS-related activities or events, including but not limited to:

• Any activity or event on property owned or controlled by the RFHS;

• Learner placements, practical, or clinical training;

• RFHS research activities, whether on or off campus;

• Learner and/or employee exchanges arranged in connection with the RFHS;

• Social events or networking, where matters regarding the RFHS or members of the RFHS community are a significant focus of the activity;

• Experiential Learning activities such as RFHS field trips, travel-study tours and service-learning;

b) Activities or events involving members of the RFHS community, where the actions of those members of the RFHS community may reasonably reflect upon or affect the RFHS, including but not limited to:

• Any aspect of the employment or engagement of employees and contractors for roles and projects substantially connected to the RFHS;

• Writings, photographs, artwork, audio or video recordings, and/or electronic communications, including communications through social media, where matters regarding the RFHS community are a significant focus of the communication;

• Matters related to The University of Manitoba Students’ Union, the Graduate Students’ Association, and their affiliated learner groups to the extent that it affects the proper functioning of the RFHS or the rights of a member of the RFHS community to use and enjoy the RFHS’s learning and working environments; or

• Matters of off-campus conduct that have, or might reasonably be seen to have an adverse effect on the proper functioning of the RFHS or the rights of a member of the RFHS community to use and enjoy the RFHS’s learning and working environments.

“Reviewer” means that if the determination means that if the determination is to proceed with the matter, the College/IHP/SDH lead, with the Office of Professionalism, will determine the appropriate individual to review the matter (the “Reviewer”). There may be more than one Reviewer (depending on the nature of the complaint, see Section 3.9 below). The Reviewer(s) may be the supervisor of the Respondent (such as the department head, section head, director, residency director, an associate/assistant dean, director, College/IHP/SDH lead, etc.). In cases where the Respondent is not a member of the RFHS, the matter will be referred to the immediate supervisor of the Respondent for attention, the health professional leader of the unit will also be notified e.g. if a site employee is the Respondent, their supervisor will be notified of the complaint.

“Staff Member” means administrative or support staff employed by the Colleges or the Rady Faculty of Health Sciences that are not academic staff.

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3. Guidelines / PROCEDURE STATEMENTS

3.1 The Rady Faculty of Health Sciences and its Colleges and are committed to ensuring safe, respectful and supportive working and learning environments in which all of the RFHS community are enabled and encouraged to excel. This is an environment free of discrimination, harassment and Learner Mistreatment and one in which feedback regarding performance can be shared openly without concern for ridicule or reprisal. All members of our diverse community share responsibility for maintaining a positive learning environment and for taking appropriate steps to seek advice and/or address Learner Mistreatment when it occurs, as defined in the Procedures section.

3.2 Keep It Up Button

The Rady Faculty of Health Sciences would like to acknowledge members of its Faculty making a difference in learners’ education in a positive way, and those who are improving the learner environment and the quality of teaching. Learners are encouraged to use the Keep It Up Button, an electronic anonymous vehicle to acknowledge excellence in teaching.

Informal Procedure to Report Mistreatment

3.3 Learners can report concerns about Learner Mistreatment in their learning environment to any of their teachers, instructors, preceptors, course/rotation directors, administrative staff members, department heads, associate deans within their program, director IHP, Student Advocacy office and the Office of Human Rights and Conflict Management, according to their own personal comfort and preference. Learners should recognize that not all teachers, leaders, or staff members are equally well placed to provide assistance or other support in response to Learner Mistreatment behavior, nor are they all equally capable of acting on the report to effectively address the particular incident.

3.4 Learners may also make reports via learner representatives. A learner representative may be a support person (e.g. friend or family member), student advocate or other individual appointed by the learner as their representative. Learner representatives can discuss reports of Learner Mistreatment with the relevant course/rotation director, department head, director IHP, or an associate dean while maintaining the anonymity of the Complainant.

3.5 Individuals to whom an informal report is made shall make the learner aware of these Guidelines and are encouraged to suggest to learners to also complete a mistreatment report form (Speak Up Button) or to another appropriate forum (see Appendix A) to ensure that appropriate follow-up takes place. Alternatively or additionally, the individual receiving an informal report of Learner Mistreatment may themselves complete a Learner Mistreatment report form anonymously on the reporting learner’s behalf.

Speak Up Button: Formal Procedure to Report Learner Mistreatment

3.6 Learner Mistreatment Report Form: Speak Up Button

The Speak Up Button, an electronic mistreatment report form, provides learners with a convenient, effective, and confidential means to make a report of Learner Mistreatment; it is available online at [provide link once available at RFHS level]. The Speak Up Button is a conduit for learners to report, whether or not the matter falls within the jurisdiction of these Guidelines.

3.7 Anonymous Reporting

Although there is an option for anonymous reporting of Learner Mistreatment, the Rady Faculty of Health Sciences’ response to anonymous reports may be limited when it cannot follow up with the person making the report. Individuals are encouraged to make reports that are not anonymous, but the RFHS acknowledges the imperative of anonymous reporting in some circumstances.

3.8 Receipt of Learner Mistreatment Reports

The Confidential Intake Officer (CIO) in the Office of Professionalism receives all Learner Mistreatment Reports via the Speak Up Button. The Mistreatment Report Forms will be reviewed by the CIO within 10 working days or as soon thereafter as is reasonably possible. The CIO will acknowledge receipt of the complaint as soon as it has been reviewed by the CIO, and will arrange for a brief telephone discussion to obtain any further relevant information, and to arrange for a subsequent meetings (with either the Associate and/or Assistant Deans of Professionalism in the case of Max Rady College, or with the College/IHP/SDH lead, see below 3.9). In the initial call to the Complainant, the Complainant will be reassured that where possible all discussions are confidential and that the Complainant has the right, at any stage, to withdraw the complaint (note that not all disclosures can remain confidential or be withdrawn, see sections 3.14 and 3.17)

3.9 Jurisdiction and referrals

Each College/IHP has jurisdiction to consider Learner Mistreatment matters not covered by other jurisdictions (see Appendix A). Matters considered of a serious nature or involving alleged egregious behavior, are referred to the appropriate forum/body. For clarity, the Office of Professionalism will refer all reports respecting harassment, discrimination, or sexual violence, as covered by the University’s Respectful Work and Learning Environment Policy and Sexual Violence Policy, to the Office of Human Rights and Conflict Management. Cases involving sexual violence can also be referred to the Sexual Violence Resource Centre. If a referral is to be made to another body by the Office of Professionalism, the Complainant will first be notified.

3.10 College/IHP/SDH Lead

Each College/IHP/SDH will appoint one (or more) person(s) to be an initial point of contact (College/IHP/SDH lead) for the Office of Professionalism for reports within that College/IHP/SDH. This individual(s) may be a dean, associate dean, similar position, or designate. Should a College/IHP/SDH lead be in a conflict of interest (as defined in the Conflict of Interest Policy) respecting a particular matter, the College/IHP/SDH will appoint another individual as the College/IHP/SDH lead for that matter.

3.11 Preliminary Assessment/Decision to Proceed

The Associate/Assistant Deans of Professionalism (for Max Rady College complaints), and the College/IHP/SDH leads (for all others), with the CIO, will speak to the Complainant as outlined above. If the Complainant agrees to proceed, the Associate/Assistant Deans of Professionalism (for Max Rady College complaints), or the College/IHP/SDH leads, with the CIO, will determine the most appropriate Reviewer(s)(see section 2.1) e.g. a minor complaint about a resident physician, will usually be referred to the residency director as the Reviewer; a minor complaint about academic staff will usually be referred to the section or department head as the Reviewer; in those deemed more serious, the Reviewer(s) may be the department head and the Associate/Assistant Deans Professionalism (Max Rady College) or the College/IHP/SDH lead. The Reviewer(s) will then inform the Respondent of the complaint and will arrange to discuss the complaint with the Respondent and to obtain any relevant preliminary information. The Reviewer(s), when informing the Respondent of the complaint (for preliminary assessment purposes), will ensure that they follow the principles of procedural fairness; ensuring the Respondent is advised in advance why they are being contacted, and of their right to advocacy support. After the Reviewer(s) have had a preliminary discussion with the Respondent, a decision will be made by the Associate/Assistant Deans of Professionalism (for Max Rady College complaints), and the College/IHP/SDH leads, together with the CIO, whether to proceed or not. When it is determined not to proceed, the Complainant will be notified either by phone or in writing.

3.12 Informal Resolution

Where both parties agree, the Reviewer(s) may assist with informally resolving the matter. This would entail reaching an agreeable solution for both parties by means of either a face-to-face meeting or done verbally with the Reviewer acting as a go- between. Should this informal process not result in a resolution, the review will continue. Depending on the nature of the complaint, most matters can be resolved with the Reviewer(s) acting as a facilitator. Communication can be either face-to-face with both parties, or most often with the Reviewer(s) as a go between. Once the matter has been resolved, the Complainant is notified in writing by the College/IHP/SDH lead that the complaint is closed.

3.13 Review

The Reviewer(s) will conduct a review in accordance with the principles of procedural fairness and natural justice, including interviewing the Complainant, informing the Respondent about the complaint, interviewing the Respondent and providing the Respondent with a reasonable opportunity to respond, and interviewing any other persons who might have insight into the situation, such as witnesses and individuals in relevant positions. The Reviewer(s) may also examine any physical evidence such as documents and records that may be available. The Reviewer(s) may also conduct a joint review, including without limitation, with an affiliated clinical learning site, the Faculty of Graduate Studies, another Faculty, or the Office of Human Rights and Conflict Management. All such individuals will be bound to strict confidentiality regarding all aspects of the review. The Reviewer(s) will then make a decision on the corrective/remedial action to be taken, inform the parties of findings, and ensure any corrective action is taken. Before meeting with an UMFA member, the Reviewer(s) will notify the dean of the College and seek the advice of Staff Relations.

3.14 Withdrawal of Complaint

The Complainant has a right to withdraw the complaint at any stage. However, the Reviewer(s)s and the College/IHP/SDH lead may elect to elect continue the review in compliance with obligations to ensure an environment free from Learner Mistreatment.

3.15 Appeals

In cases where either the Complainant or the Respondent are dissatisfied with the Reviewer’s decision, that person must initate their appeal in writing to RFHS Dean or designate within 10 working days of the report and refer to the applicable University Policy, Procedure or Bylaw or collective agreement.

3.16 Special Note regarding Post Graduate Medical Learners

Residents may report incidents of mistreatment using the formal procedure described in these Guidelines (Speak Up), or they may use the Learner Mistreatment Tool in the Max Rady Entrada Curriculum Management System. In either procedure, the processes outlined in sections 3.9 - 3.15 will apply.

3.17 Confidentiality & Record Keeping

Any communication of information gathered in any case is confidential. All personal and personal health information collected, used, and disclosed will be done so in accordance with the University’s obligations under The Freedom of Information and Protection of Privacy Act and The Personal Health Information Act.

The Rady Faculty of Health Sciences will not disclose the name of a Complainant or Respondent or the circumstances related to a complaint except to the extent that disclosure is necessary to effectively implement these Guidelines, to undertake any remedial action arising from these Guidelines or where there is a perceived risk to the health and safety of a community member. Records will be kept pursuant to any applicable relevant University Policy and/or Procedure.

3.18 Institutional Responsibility

Aggregate and de-identified data on formal and informal reports of mistreatment of learners will be shared by the Office of Professionalism with the dean/director, the Rady Faculty of Health Sciences Dean’s Council and the Department Heads Council, where relevant, on a biannual basis. The College/IHP/SDH leadership are responsible for actively addressing concerning rates of trends of Learner Mistreatment.

3.19 Remedial Measures

Remedial measures, where determined to be appropriate, resulting from a Learner Mistreatment concern related to a RFHS matter will depend on the circumstances, on the seriousness of the behavior, on any mitigating factors and on applicable University policy, bylaw, collective agreement or academic regulation. The following list provides examples of remedial measures and is not meant to be exhaustive nor necessarily represents a progression of measures:

a) A letter of apology;

b) Attendance at educational session(s) on professionalism;

c) Attendance at coaching session(s) to improve communication or conflict resolution skills;

d) Prohibited or restricted access to the learning environment and/or to learners;

e) Academic consequences such as remediation, probation, notation on the performance record, dismissal/expulsion from College, termination of academic appointment.

3.20 Retaliation

A Complainant, Respondent, witness, and/or any other person who has sought advice regarding Learner Mistreatment, who has brought forward allegations, who has made a report or who has cooperated with a review , is entitled to be protected from retaliation. Retaliatory action of any sort during or following the review is prohibited and will not be tolerated. This includes any joint reviews affecting the clinical work and learning environment at U of M affiliated health-care sites.

There are many supports to assist in addressing one’s concerns about retaliation. The Speak Up button [hyperlink when available] can be utilized. Learners may contact their Student Affairs office and Student Services at Bannatyne Campus representatives, including Student Advocacy. All concerns and complaints raised in accordance with applicable policies will be thoroughly reviewed and investigated, and any breaches appropriately addressed. Accusations that retaliation has occurred will be subject to investigation and may result in disciplinary action in accordance with the applicable Policy or Collective Agreement. A learner can challenge a reprisal through an appeal process set out in the Student Discipline Bylaw, the Academic Appeal Policy relating to their program, or other applicable discipline or academic appeal routes within the University.

3.21 False Accusations

A Complainant or witness found to have been dishonest in making allegations with a conscious design to mislead or deceive, or with a malicious or fraudulent intent may be subject to disciplinary action in accordance with the applicable Policy or Collective Agreement.

3.22 Communication and Education

These Guidelines will be included in learner handbooks and posted on the Rady Faculty of Health Sciences’ website; the topic will be addressed at orientations at matriculation and in the year that the learner’s clinical/fieldwork education component commences.

Mandatory educational sessions for academic staff and leadership will be held at least once a year under the direction of the Office of Professionalism, Rady Faculty of Health Sciences.

A letter will be sent each year from the dean of each College and the College/ IHP Lead to all Faculty (including voluntary Faculty) reminding them of the Rady Faculty of Health Sciences statement on supporting a Learner Mistreatment-free environment, of these Guidelines on the Prevention Learner Mistreatment and on resources available for resolution. Further communication mechanisms or modules may be developed.

A letter will be sent each year from the Dean of the Rady Faculty of Health Sciences to the Chief Executive Officer at affiliated institutions to explain these Guidelines and to request its distribution to all staff interacting with learners from the Rady Faculty of Health Sciences.

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4. SUPPORTS

The RFHS recognizes that although most matters of Learner Mistreatment are addressed in a restorative, non punitive manner, the process can be stressful for all parties involved. Complainants and Respondents are encouraged to obtain support through UGME Student Affairs https://umanitoba.ca/medicine/student-experience and PGME Student Affairs https://umanitoba.ca/medicine/student-experience , Services for Students at Bannatyne https://umanitoba.ca/student-supports/student-services- bannatyne-campus and the Student Advoacy Office https://umanitoba.ca/student- supports/academic-supports/student-advocacy

In addition to the above supports, both Complainants and Respondents may wish to connect with the Ombudsperson, a neutral resource who can act as a resource through the process (contact through the Office of Professionalism).

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5. GUIDELINES CONTACT

Please contact the Office of Professionalism, Rady Faculty of Health Sciences, with questions respecting these Guidelines.

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6. REFERENCES

6.1 Keep It Up

6.2 Speak Up

6.3 The University of Manitoba Respectful Work and Learning Environment (RWLE) Policy

6.4 The University of Manitoba Sexual Violence Policy

6.5 The University of Manitoba Disclosures and Complaints Procedure

6.6 The University of Manitoba Student Discipline Bylaw and Procedures

6.7 The University of Manitoba Violent or Threatening Behaviour Policy and Procedure

6.8 The University of Manitoba Responsibilities of Academic Staff with Regard to Students Policy and Procedure

6.9 The Human Rights Code, C.C.S.M. c. H175 

6.10 Rady Faculty of Health Sciences Disruption of all Forms of Racism Policy

6.11 Conflict of Interest Policy

6.12 Appendix A - Jurisdiction Referrals and Review (PDF)

Documents will be supplied in alternate formats on request.

Policy name	Prevention of learner mistreatment
Application and scope	Faculty, staff and learners of the Max Rady College of Medicine
Approved date	June 5, 2018
Review date	Five (5) years from the revised date
Revised date	May 3, 2022
Approved by	Dean’s Council, Max Rady College of Medicine March 22, 2022; Max Rady College of Medicine College Executive Council May 3, 2022

1. PURPOSE

The purpose of this Policy is to:

(a) Acknowledge the importance of a safe learning environment for all. Mistreatment of learners has negative consequences for learner well-being and functioning of teams. Learner Mistreatment truncates learning and impacts patient safety. This Policy strives to create an environment free of mistreatment where learners feel safe to report.

(b) Define Learner Mistreatment in any learning environment, including without limitation academic learning environments and clinical learning environments.

(c) To set out clear mechanisms and procedures for learners to report mistreatment against them, or mistreatment that learners observe against others, without fear of retaliation.

(d) Ensure compliance with relevant accreditation standards applicable to the educational programs offered by the Max Rady College of Medicine.

(e) Be aligned with existing policies at the University of Manitoba. This Policy is meant to be consistent and compliant with existing University of Manitoba policies and bylaws. Where any portion of this Policy conflicts with these University policies/bylaws, the latter will govern.

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2. DEFINITIONS

2.1 The terms in this Definition section are defined for the purposes of this Policy.

“Academic Staff” refers to all individuals whose primary assignment is instruction, research, and/or service/academic administration. This includes employees who hold an academic rank such as professor, associate professor, assistant professor, instructor, lecturer, librarian, or the equivalent of any of those academic ranks. The category also includes a dean, director, associate dean, assistant dean, chair or head of department, visiting scholars, senior scholars, and those holding unpaid academic appointments, insofar as they perform instructional, research, and/or service/academic administrative duties. This includes non-unionized academic staff of the Max Rady College of Medicine, visiting professors, clinicians with academic appointments and including academic staff whose salary or stipend may be paid, in whole or in part, by another organization.

“Learner” means an individual registered, enrolled, or classified as a student, resident, trainee or fellow within or with the University of Manitoba, Max Rady College of Medicine.

“Confidential” means the University’s obligation to handle personal information and personal health information in accordance to The Freedom of Information and Protection of Privacy Act and The Personal Health Information Act.

“Complainant” means the individual or individuals bringing forward a report of mistreatment.

"Respondent" means an individual or individuals accused of having caused or contributed to mistreatment.

“Learner Mistreatment” means an intentional, or unintentional, disrespectful treatment occurring by any individual against a learner or colleague that has or may have the effect of creating an intimidating, humiliating, hostile or offensive work or learning environment for learners in that circumstance. It entails behavior that shows disrespect for the dignity of others and can take the form of physical or psychological punishment, harassment or discrimination.

Examples of mistreatment include, but are not limited to:

(a) Actions or criticism conducted in public that can be interpreted as embarrassing or humiliating.

(b) Verbally abusing, belittling, ridiculing or yelling at a learner in public or private.

(c) Speaking to a learner in a sarcastic or insulting manner.

(d) Subjecting the learner to racially or ethnically offensive remarks or names.

(e) Requiring a learner to perform personal services (i.e. babysitting, shopping).

(f) Pressuring learners to exceed established restrictions on work or duty hours.

(g) Not providing learners with clear learning/work expectations yet holding them responsible for the expectations.

(h) Directing learners to perform an unreasonable number of routine hospital or clinical procedures where performing those activities interferes with a learner’s attendance at educational activities, (e.g. rounds, classes).

(i) Disparaging the learner’s choice of residency, profession, or other career aspirations.

(j) Intentional physical contact such as pushing, shoving, slapping, hitting, tripping.

(k) Subjecting the learner to threatening gestures.

(l) Excluding a learner from reasonable learning opportunities.

(m) Using grades as punishment rather than as an objective evaluation of performance.

(n) Assigning duties as punishment rather than education.

(o) Threatening to fail, give lower grades, or give a poor evaluation for anything other than documented performance issues.

(p) Intentionally neglecting or excluding the learner from communications.

(q) Intentionally singling out a learner for arbitrary treatment that could be perceived as punitive.

Learner Mistreatment is not:

• A supervisor or manager to engage in the legitimate evaluation of the performance of an employee or contractor, or otherwise overseeing their work;

• Academic staff to engage in the academic evaluation of a learner’s work;

• A good faith and formal evaluation of an academic staff member or supervisor to be conducted;

• A legitimate peer review or other critique of research or academic work to be conducted;

• A unit head to take actions intended to address or deter violent, threatening, or intimidating behaviour, or behaviour which significantly disrupts the University and members of the University community.

"Max Rady College of Medicine Community" means all Max Rady College of Medicine (College) members including Faculty/College/School Councils, employees, anyone holding an appointment with the College, learners, volunteers, external parties conducting business within the College, contractors and suppliers within the College.

"Max Rady College of Medicine Matter" means any activity, event, or undertaking in which a member of the College community participates, which has a substantial connection to the College, such as:

a) College-related activities or events, including but not limited to:

• Any activity or event on property owned or controlled by the College;

• Learner placements, practical, or clinical training;

• College research activities, whether on or off campus;

• Learner and/or employee exchanges arranged in connection with the College;

• Social events or networking, where matters regarding the College or members of the College community are a significant focus of the activity;

• Experiential Learning activities such as College field trips, travel-study tours and service-learning;

b) Activities or events involving members of the College community, where the actions of those members of the College community may reasonably reflect upon or affect the College, including but not limited to:

• Any aspect of the employment or engagement of employees and contractors for roles and projects substantially connected to the College;

• Writings, photographs, artwork, audio or video recordings, and/or electronic communications, including communications through social media, where matters regarding the College community are a significant focus of the communication;

• Matters related to The University of Manitoba Students’ Union, the Graduate Students’ Association, and their affiliated learner groups to the extent that it affects the proper functioning of the College or the rights of a member of the College community to use and enjoy the College’s learning and working environments; or

• Matters of off-campus conduct that have, or might reasonably be seen to have an adverse effect on the proper functioning of the College or the rights of a member of the College community to use and enjoy the College’s learning and working environments.

“Reviewer” means that if the determination is to proceed with the matter, the Office of Professionalism will determine the appropriate individual to review the matter (the “Reviewer”). There may be more than one Reviewer (depending on the nature of the complaint, see Section 3.9 below). The Reviewer(s) may be the supervisor of the Respondent (such as the department head, section head, director, residency director, an associate/assistant dean, director, etc.). In cases where the Respondent is not a member of the College, the matter will be referred to the immediate supervisor of the Respondent for attention, the health professional leader of the unit will also be notified e.g. if a site employee is the Respondent, their supervisor will be notified of the complaint.

“Staff Member” means administrative or support staff employed by the College that are not academic staff.

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3. POLICY / PROCEDURE STATEMENTS

3.1 The Max Rady College of Medicine is committed to ensuring safe, respectful and supportive working and learning environments in which all of the College community are enabled and encouraged to excel. This is an environment free of discrimination, harassment and Learner Mistreatment and one in which feedback regarding performance can be shared openly without concern for ridicule or reprisal. All members of our diverse community share responsibility for maintaining a positive learning environment and for taking appropriate steps to seek advice and/or address Learner Mistreatment when it occurs, as defined in the Procedures section.

3.2 Keep It Up Button

The Max Rady College of Medicine would like to acknowledge members of its Faculty making a difference in learners’ education in a positive way, and those who are improving the learner environment and the quality of teaching. Learners are encouraged to use the Keep It Up Button, an electronic anonymous vehicle to acknowledge excellence in teaching.

Informal Procedure to Report Mistreatment

3.3 Learners can report concerns about Learner Mistreatment in their learning environment to any of their teachers, instructors, preceptors, course/rotation directors, administrative staff members, department heads, associate deans within their program, Student Advocacy office and the Office of Human Rights and Conflict Management, according to their own personal comfort and preference. Learners should recognize that not all teachers, leaders, or staff members are equally well placed to provide assistance or other support in response to Learner Mistreatment behavior, nor are they all equally capable of acting on the report to effectively address the particular incident.

3.4 Learners may also make reports via learner representatives. A learner representative may be a support person (e.g. friend or family member), student advocate or other individual appointed by the learner as their representative. Learner representatives can discuss reports of Learner Mistreatment with the relevant course/rotation director, department head, or an associate dean while maintaining the anonymity of the Complainant.

3.5 Individuals to whom an informal report is made shall make the learner aware of this Policy and are encouraged to suggest to learners to also complete a mistreatment report form (Speak Up Button) or to another appropriate forum (see Appendix A) to ensure that appropriate follow-up takes place. Alternatively or additionally, the individual receiving an informal report of Learner Mistreatment may themselves complete a Learner Mistreatment report form anonymously on the reporting learner’s behalf.

Speak Up Button: Formal Procedure to Report Learner Mistreatment

3.6 Learner Mistreatment Report Form: Speak Up Button

The Speak Up Button, an electronic mistreatment report form, provides learners with a convenient, effective, and confidential means to make a report of Learner Mistreatment; it is available online at Speak Up. The Speak Up Button is a conduit for learners to report, whether or not the matter falls within the jurisdiction of this Policy.

3.7 Anonymous Reporting

Although there is an option for anonymous reporting of Learner Mistreatment, the College’s response to anonymous reports may be limited when it cannot follow up with the person making the report. Individuals are encouraged to make reports that are not anonymous, but the College acknowledges the imperative of anonymous reporting in some circumstances.

3.8 Receipt of Learner Mistreatment Reports

The Confidential Intake Officer (CIO) in the Office of Professionalism receives all Learner Mistreatment Reports via the Speak Up Button. The Mistreatment Report Forms will be reviewed by the CIO within 10 working days or as soon thereafter as is reasonably possible. The CIO will acknowledge receipt of the complaint, once it has been reviewed by the CIO, will arrange for a brief telephone discussion to obtain any further relevant information, and to arrange a subsequent meeting (with either the Associate and/or Assistant Deans of Professionalism, see below 3.9). In the initial call to the Complainant, the Complainant will be reassured that where possible all discussions are confidential and that the Complainant has the right, at any stage, to withdraw the complaint (note that not all disclosures can remain confidential or be withdrawn, see sections 3.13 and 3.16)

3.9 Jurisdiction and referrals

The College has jurisdiction to consider Learner Mistreatment matters not covered by other jurisdictions (see (see Appendix A). Matters considered of a serious nature or involving alleged egregious behavior are referred to the appropriate forum/body. For clarity, the Office of Professionalism will refer all reports respecting harassment, discrimination, or sexual violence, as covered by the University’s Respectful Work and Learning Environment Policy and Sexual Violence Policy, to the Office of Human Rights and Conflict Management. Cases involving sexual violence can also be referred to the Sexual Violence Resource Centre. If a referral is to be made to another body by the Office of Professionalism, the Complainant will first be notified.

3.10 Preliminary Assessment/Decision to Proceed

The Associate/Assistant Deans of Professionalism with the CIO, will speak to the Complainant as outlined above. If the Complainant agrees to proceed, the Associate/Assistant Deans of Professionalism, with the CIO, will determine the most appropriate Reviewer(s)(see section 2.1) e.g. a minor complaint about a resident physician, will usually be referred to the residency director as the Reviewer; a minor complaint about academic staff will usually be referred to the section or department head as the Reviewer; in those deemed more serious, the Reviewer(s) may be the department head and the Associate/Assistant Deans Professionalism. The Reviewer(s) will then inform the Respondent of the complaint and will arrange to discuss the complaint with the Respondent and to obtain any relevant preliminary information. The Reviewer(s), when informing the Respondent of the complaint (for preliminary assessment purposes), will ensure that they follow the principles of procedural fairness; ensuring the Respondent is advised in advance why they are being contacted, and of their right to advocacy support. After the Reviewer(s) have had a preliminary discussion with the Respondent, a decision will be made by the Associate/Assistant Deans of Professionalism together with the CIO, whether to proceed or not. When it is determined not to proceed, the Complainant will be notified either by phone or in writing.

3.11 Informal Resolution

Where both parties agree, the Reviewer(s) may assist with informally resolving the matter. This would entail reaching an agreeable solution for both parties by means of either a face-to-face meeting or done verbally with the Reviewer acting as a go- between. Should this informal process not result in a resolution, the review will continue. Depending on the nature of the complaint, most matters can be resolved with the Reviewer(s) acting as a facilitator. Communication can be either face-to-face with both parties, or most often with the Reviewer(s) as a go between. Once the matter has been resolved, the Complainant is notified in writing by the College that the complaint is closed.

Review

The Reviewer(s) will conduct a review in accordance with the principles of procedural fairness and natural justice, including interviewing the Complainant, informing the Respondent about the complaint, interviewing the Respondent and providing the Respondent with a reasonable opportunity to respond, and interviewing any other persons who might have insight into the situation, such as witnesses and individuals in relevant positions. The Reviewer(s) may also examine any physical evidence such as documents and records that may be available. The Reviewer(s) may also conduct a joint review, including without limitation, with an affiliated clinical learning site, the Faculty of Graduate Studies, another Faculty, or the Office of Human Rights and Conflict Management. All such individuals will be bound to strict confidentiality regarding all aspects of the review. The Reviewer(s) will then make a decision on the corrective/remedial action to be taken, inform the parties of findings, and ensure any corrective action is taken. Before meeting with an UMFA member, the Reviewer(s) will notify the dean of the College and seek the advice of Staff Relations.

3.13 Withdrawal of Complaint

The Complainant has a right to withdraw the complaint at any stage. However, the Reviewer(s) may elect to elect continue the review in compliance with obligations to ensure an environment free from Learner Mistreatment.

3.14 Appeals

In cases where either the Complainant or the Respondent are dissatisfied with the Reviewer’s decision, that person must initiate their appeal in writing to RFHS Dean or designate within 10 working days of the report and refer to the applicable University Policy, Procedure or Bylaw or collective agreement.

3.15 Special Note regarding Post Graduate Medical Learners

Residents may report incidents of mistreatment using the formal procedure described in this Policy (Speak Up), or they may use the Learner Mistreatment Tool in the Max Rady Entrada Curriculum Management System. In either procedure, the processes outlined in sections 3.9 - 3.14 will apply.

3.16 Confidentiality & Record Keeping

Any communication of information gathered in any case is confidential. All personal and personal health information collected, used, and disclosed will be done so in accordance with the University’s obligations under The Freedom of Information and Protection of Privacy Act and The Personal Health Information Act.

The College will not disclose the name of a Complainant or Respondent or the circumstances related to a complaint except to the extent that disclosure is necessary to effectively implement this Policy, to undertake any remedial action arising from this Policy or where there is a perceived risk to the health and safety of a community member. Records will be kept pursuant to any applicable relevant University Policy and/or Procedure.

3.17 Institutional Responsibility

Aggregate and de-identified data on formal and informal reports of mistreatment of learners will be shared by the Office of Professionalism with the Dean’s Council and Department Heads Council, where relevant, on a biannual basis. The College leadership are responsible for actively addressing concerning rates of trends of Learner Mistreatment.

3.18 Remedial Measures

Remedial measures, where determined to be appropriate, resulting from a Learner Mistreatment concern related to a College Matter will depend on the circumstances, on the seriousness of the behavior, on any mitigating factors and on applicable University policy, bylaw, collective agreement or academic regulation. The following list provides examples of remedial measures and is not meant to be exhaustive nor necessarily represents a progression of measures:

a) A letter of apology;

b) Attendance at educational session(s) on professionalism;

c) Attendance at coaching session(s) to improve communication or conflict resolution skills;

d) Prohibited or restricted access to the learning environment and/or to learners;

e) Academic consequences such as remediation, probation, notation on the performance record, dismissal/expulsion from College, termination of academic appointment.

3.19 Retaliation

A Complainant, Respondent, witness, and/or any other person who has sought advice regarding Learner Mistreatment, who has brought forward allegations, who has made a report or who has cooperated with a review , is entitled to be protected from retaliation. Retaliatory action of any sort during or following the review is prohibited and will not be tolerated. This includes any joint reviews affecting the clinical work and learning environment at U of M affiliated health-care sites.

There are many supports to assist in addressing one’s concerns about retaliation. The Speak Up can be utilized. Learners may contact their Student Affairs office and Student Services at Bannatyne Campus representatives, including Student Advocacy. All

concerns and complaints raised in accordance with applicable policies will be thoroughly reviewed and investigated, and any breaches appropriately addressed. Accusations that retaliation has occurred will be subject to investigation and may result in disciplinary action in accordance with the applicable Policy or Collective Agreement. A learner can challenge a reprisal through an appeal process set out in the Student Discipline Bylaw, the Academic Appeal Policy relating to their program, or other applicable discipline or academic appeal routes within the University.

3.20 False Accusations

A Complainant or witness found to have been dishonest in making allegations with a conscious design to mislead or deceive, or with a malicious or fraudulent intent may be subject to disciplinary action in accordance with the applicable Policy or Collective Agreement.

3.21 Communication and Education

This Policy will be included in learner handbooks and posted on the Colleges’ website; the topic will be addressed at orientations at matriculation and in the year that the learner’s clinical/fieldwork education component commences.

Mandatory educational sessions for academic staff and leadership will be held at least once a year under the direction of the Office of Professionalism.

A letter will be sent each year from the Dean of the Rady Faculty of Health Sciences to all Faculty (including voluntary Faculty) reminding them of the College’s statement on supporting a Learner Mistreatment-free environment, of this Policy on the Prevention Learner Mistreatment and on resources available for resolution. Further communication mechanisms or modules may be developed.

A letter will be sent each year from the Dean of the Rady Faculty of Health Sciences to the Chief Executive Officer at affiliated institutions to explain this Policy and to request its distribution to all staff interacting with learners from the College.

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4. SUPPORTS

The College recognizes that although most matters of Learner Mistreatment are addressed in a restorative, non-punitive manner, the process can be stressful for all parties involved. Complainants and Respondents are encouraged to obtain support through UGME Student Affairs and PGME Student Affairs , Services for Students at Bannatyne and Student Advocacy. In addition to the above supports, both Complainants and Respondents may wish to connect with the Ombudsperson, a neutral resource who can act as a resource through the process (contact through the Office of Professionalism).

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5. POLICY CONTACT

Please contact the Office of Professionalism, Max Rady College of Medicine, with questions respecting this Policy.

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6. REFERENCES

6.1 Keep It Up

6.2 Speak Up

6.3 The University of Manitoba Respectful Work and Learning Environment (RWLE) Policy

6.4 The University of Manitoba Sexual Violence Policy

6.5 The University of Manitoba Disclosures and Complaints Procedure

6.6 The University of Manitoba Student Discipline Bylaw and Procedures

6.7 The University of Manitoba Violent or Threatening Behaviour Policy and Procedure

6.8 The University of Manitoba Responsibilities of Academic Staff with Regard to Students Policy and Procedure

6.9 The Human Rights Code, C.C.S.M. c. H175 

6.10 Rady Faculty of Health Sciences Disruption of all Forms of Racism Policy

6.11 Conflict of Interest Policy

6.12 Appendix A - Jurisdiction Referrals and Review (PDF)

Documents will be supplied in alternate formats on request.

1. PURPOSE

Because of innumerable appropriate dress choices, attire guidelines /dress code can be difficult to concisely define. This guideline is intended to provide general principles to be considered for attire (including personal grooming decisions) for staff, faculty members, and learners within the RFHS and its Colleges, to ensure safe learning and work environments, and is intended to respect equity, diversity and promotion of inclusion.

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2. GUIDELINES

2.1 Staff, faculty members and learners have the right to express themselves, including in decisions about attire, along with a shared responsibility to maintain respectful, safe and positive learning and working environments.

2.2 Attire should be respectful of a community that is anti-oppressive, equitable, accepting and inclusive of a diverse range of social and cultural identities. Dress shall not promote offensive, harassing, hostile or intimidating environments.

2.3 Discretion and good judgment should be exercised in attire, taking into consideration:

• The safe performance of work or learning duties, so that dress does not interfere with health or safety requirements for the intended activity;
• The specific work or learning environment, ensuring that attire is appropriate to the environment;
• Interactions with clients, business contacts, learners, faculty members and staff;
• The importance of reducing the risk of spreading pathogens from person-to-person.

2.4 Scented products should be avoided, recognizing that some individuals have allergies and/or are sensitive to certain chemicals in scented products. Fragrances and other scented hygiene products shall not be used/worn in designated scent free zones. In areas that are not designated scent free zones, fragrances and scented hygiene products shall be used/worn in moderation and shall abide by any directions received in regard to the limitation or use of products with scents and/or fragrances to accommodate those with scent and/or fragrance allergies.

2.5 This guideline is not intended to replace more detailed College or Program-specific policies, such as learner attire in clinical settings. Please reference applicable college- or program-specific policies or guidelines.

2.6 Should there be an issue identified respecting an individual’s attire, please contact the appropriate manager, Human Resources, or learner authority (program director, associate dean, etc.) for consultation and direction. Enforcement of individual attire or dress code requirements should not reinforce or increase marginalization or oppression of any individual or group based on any of the personal characteristics as set out in the Human Rights Code (Manitoba). The Office of Human Rights and Conflict Management may also be consulted.

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3 REFERENCES

3.1 The Human Rights code (Manitoba) C.C.S.M. c. H175

3.2 The Respectful Workplace and Learning Environment Policy, University of Manitoba

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4. GUIDELINE CONTACT

Please contact the Director, Planning & Priorities, Rady Faculty of Health Sciences, with questions regarding this document.

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5. APPROVAL

These guidelines were approved by the RFHS Dean’s Council on April 28, 2020.

Policy name	Booking Clinical Learning and Simulation Program (CLSP) resources
Policy number	SIM - 5001
Application and scope	All rooms / resources booked through CLSP
Approved date	April 28, 2020
Review date	Five (5) years from the approval date
Revised date
Approved by	Dean’s Council, Rady Faculty of Health Sciences

BACKGROUND

The Clinical Learning and Simulation Program (CLSP) is a shared Rady Faculty of Health Sciences (RFHS) and Winnipeg Regional Health Authority resource that provides simulation-based education space, equipment, supplies and expertise to a vast array of learner groups. The CLSP currently manages bookings for simulation space, related staff, equipment and supplies. In addition, the CLSP also manages bookings to support mobile (in-situ) simulations and also provides equipment and supply loans for offsite use. The volume of use in the CLSP often strains the capacity to provide these services. Due to the volume of requests submitted to the CLSP, it is not always possible to provide all users with their first choice of resource bookings.

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1. PURPOSE

To ensure fair and equitable booking of CLSP Resources available to User Groups, and to effectively manage the availability of resources including equipment and teaching space in the CLSP.

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2. DEFINITIONS

2.1 Booking Coordinator

Means a staff member from the CLSP responsible for receiving, acknowledging and confirming bookings.

2.2 CLSP Resources

Include the simulation staff, faculty, space, supplies and equipment.

2.3 Formative Learning

Means learning activities/experiences designed to assist participants in obtaining the knowledge, skills and attitudes required for developing intraprofessional and interprofessional healthcare competencies.

2.4 Formative Assessment

Means assessments conducted during the learning process and prior to summative assessments. These assessments are used to determine whether objectives have been achieved, ascertain if gaps in learning still exist, and assess readiness to provide patient care in the clinical setting. After formative assessments, debrief with feedback should be provided and, if gaps were identified, an action plan developed jointly between the educator and learner.

2.5 Longitudinal Curriculum

Means curricula made up of multiple elements that must occur in a predetermined sequence within a tightly circumscribed time frame.

2.6 Summative Assessment

Means assessments conducted that are integrated into curricula at specific times to objectively validate achievement of a preset level of competence.

2.7 User Groups

Means users identified through CLSP as authorized to access CLSP Resources.

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3. POLICY STATEMENTS

3.1 Guiding Principles: The following principles shall guide the allocation of CLSP Resources:

a. Transparency - Every attempt will be made by the CLSP to be as transparent as possible with User Groups regarding how decisions are made with respect to accepting one booking over another and/or declining booking requests;

b. Efficiency - Given the finite resources available and at times high demand, the CLSP will attempt to maximize the use of space and resources including sharing space and/or other resources between User Groups where it makes sense or is feasible;

c. Prioritization - Space and resource allocation will be prioritized based on the type of activity being booked, not the User Group making the booking request. Please see the exception for the space in 204 Brodie as outlined in 3.3.

d. Confirmation - Once a booking is confirmed by the CLSP, User Groups should have a reasonable expectation that their booking(s) will not be cancelled or altered due to another User Group having a higher priority activity;

e. Collaboration - The CLSP will work collaboratively with User Groups to resolve conflicts in booking requests. Session organizers may be asked to provide alternate dates in order to accommodate a request from another session organizer whose priority level may not rank higher, but whose options to provide alternate dates are limited.

3.2 Annual Booking Cycle - Due to the extensive array of User Groups, and the need to have concrete dates for many curricula well in advance, the CLSP employs an Annual Booking Cycle. The Annual Booking Cycle runs from August 1st through to July 31st.

Upcoming Booking Cycle - The deadline for requests for sessions for the upcoming booking cycle (between August 1st through to July 31st of the upcoming year), is March 1st of the current booking cycle.
All booking requests received prior to the March 1st deadline will be considered based on the prioritization process outlined below. Bookings are prioritized, conflicts identified, resolved, and/or adjudicated and confirmations sent via email on or shortly after April 1st of the current booking cycle.

Requests for sessions in the upcoming booking cycle that missed the March 1st deadline will be accommodated to the best of the CLSP’s ability, but subject to resource availability.

Current Booking Cycle - Requests for sessions to occur between August 1 to July 31 of the current booking cycle will be processed and responded to within 10 business days.

Confirmation of Bookings before the Regular Notification Process - In exceptional circumstances, a User Group may request confirmation of a booking in the upcoming booking cycle ahead of the notification process noted above (i.e. a request for confirmation of a booking in the upcoming booking cycle prior to April 1st of the current booking cycle). Such confirmation will only be considered in exceptional circumstances and requires approval of the CLSP Director.

3.3 Priority Levels

For conflicts among booking requests, attempts will be made to reach a mutually satisfactory solution. However, in the event of the inability to reach a solution, the following criteria will be used as a guide to determine priority. The list below is arranged in descending order of priority. User Groups higher in the list will be given priority, on the condition that the function has been booked prior to the March 1st deadline during the Annual Booking Cycle. Final decisions regarding booking prioritization will be at the discretion of the CLSP Director.

Note: The College of Pharmacy will be given priority for booking the CLSP space in 204 Brodie as that space was developed to implement and support the PharmD program. The priority of use for other CLSP spaces will be based on the function of the space or type of activity for which the space is being booked, using the following as a guide (in order of priority):

• Activities such as conferences, courses or national licensing/qualifying exams whose dates are set externally, often well in advance, and whereby the University Manitoba has entered into a formal agreement to support the activity.
• University of Manitoba RFHS Exams or Objective Structured Clinical Examination (OSCE) whereby successful completion is required for advancement (i.e. summative assessments), whose dates are limited due to the sequential nature of learning. Justification will be required from the unit head for all such events where alternate dates cannot be provided.
• Sessions that are part of a RFHS Longitudinal Curriculum whose objectives require use of simulation resources not available outside of the CLSP, whose dates are limited due to the sequential nature of learning. Justification will be required from the unit head for all such events where alternate dates cannot be provided.
• OSCE used for advancement (i.e.) summative assessments).
• OSCE not used for advancement (i.e.) Formative Assessments).
• Sessions that are not part of a Longitudinal Curriculum whose objectives require use of simulation resources not available outside of the CLSP.
• Setup time for any of the above events.
• Sessions that potentially could be accommodated in other settings but would be better served in the CLSP.
• Other uses (tours, etc.).

3.4 Dispute Adjudication: In the event that a conflict arises that is not resolvable within the above process, the matter will be referred to the CLSP Manager and/or CLSP Director. Final decisions regarding booking prioritization will be at the discretion of the CLSP Director.

3.5 Declined Bookings: The CLSP does not commit to running all events requested, and the decision as to whether or not to host an event will be at the discretion of the CLSP Manager and/or CLSP Director. In such circumstances the reasons for declining the booking will be clearly communicated in writing to the requesting User Group.

3.6 After Hours and Weekend Bookings: As the regular operating hours for the CLSP are from 8:00AM to 4:00PM Monday to Friday, bookings within these hours are preferred. The CLSP will be closed according to the schedule of Holiday Closures posted on the Human Resources website, University of Manitoba. After hours and weekend bookings will be considered within the context of budget for overtime, overall staff work hours, and resource availability (both human and physical resources) and ultimately are at the discretion of the CLSP Manager and CLSP Director.

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4. PROCEDURE STATEMENTS

4.1 All requests for booking CLSP Resources (including but not limited to simulation-based activities, exams and tours) must be done by completing the online booking request form.

4.2 All reservations must be reserved for the actual time and space needed for experiences. Misuse of reservations may result in loss of future prioritization of booking requests from that offending User Group. No-shows or late arrivals (greater than 15 minutes) may lose the requested space for the reservation.

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5. REFERENCES

5.1 CLSP Online Booking Request Form

5.2 University of Manitoba Holiday Closure Dates

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6. POLICY CONTACT

Please contact the Director, CLSP with questions respecting this policy.

Policy name	Child safeguarding and protection policy
Application and scope	All Faculty members, staff and learners of the Rady Faculty of Health Sciences and its Colleges, University of Manitoba
Approved date	August 25, 2020
Review date	Five (5) years from approval date
Revised date
Approved by	Dean’s Council, Rady Faculty of Health Sciences: July 7, 2020 Faculty Executive Council, Rady Faculty of Health Sciences: August 25, 2020

1. APPLICATION AND SCOPE

1.1 The Rady Faculty of Health Sciences and its Colleges (“RFHS”) is committed to treating all Children with respect and dignity. It is dedicated to safeguarding and protecting the rights of all Children.

1.2 This policy incorporates the legal requirements for Child safeguarding and protection in Manitoba within the operations of the RFHS. It applies to all faculty, staff and learners of the RFHS and other individuals involved in RFHS activities, regardless of location. It applies most specifically to individuals working on projects, grants or initiatives that directly or indirectly involve Children. This policy is meant to complement, and not detract from, other applicable University policies, contractual agreements, including collective agreements, and other applicable laws.

1.3 In the event an inconsistency or conflict arises between this policy and any other applicable University policy, contractual agreement, collective agreement or law (including the law of another jurisdiction), such inconsistency or conflict shall be resolved in favour of the University policy of higher authority, or in favour of the contractual agreement or collective agreement, in accordance with the laws applicable in the Province of Manitoba, in a manner that affords the highest standards for the safeguarding and protection of Children as possible.

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2. PURPOSE

2.1 To guide learners, staff and faculty members in the safeguarding and protection of Children.

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3. DEFINITIONS

In addition to certain capitalized words and phrases that may be defined elsewhere in this policy, the following capitalized words and phrases shall have the following meanings:

3.1 Child/Children: is any individual under 18 years of age.

3.2 Abuse: as defined under section one of The CFS Act (including as such definition may be updated from time to time), an act or omission by a person where the act or omission results in:

(a) physical injury to the Child;

(b) emotional disability of a permanent nature in the Child or is likely to result in such a disability;

(c) sexual exploitation of the Child with or without the Child’s consent.

3.3 Child Neglect: is the failure of a Child’s primary caregiver to provide adequate food, clothing, shelter, supervision, and/or medical care. Child neglect involves an act of omission by a parent or guardian, resulting in (or likely to result in) harm or imminent risk of harm to a child.

3.4 CFS Act: The Child and Family Services Act (Manitoba).

3.5 In Need of Protection: Under The CFS Act, a Child is in need of protection where the life, health or emotional well-being of the Child is endangered by the act or omission of a person. Without restricting the generality of the above, a Child is in need of protection where the Child:

(a) is without adequate care, supervision or control;

(b) is in the care, custody, control or charge of a person

(i) who is unable or unwilling to provide adequate care, supervision or control of the child, or

(ii) whose conduct endangers or might endanger the life, health or emotional well-being of the Child, or

(iii) who neglects or refuses to provide or obtain proper medical or other remedial care or treatment necessary for the health or well-being of the Child or who refuses to permit such care or treatment to be provided to the Child when the care or treatment is recommended by a duly qualified medical practitioner;

(c) is abused or is in danger of being abused, including where the Child is likely to suffer harm or injury due to child pornography;

(d) is beyond the control of a person who has the care, custody, control or charge of the child;

(e) is likely to suffer harm or injury due to the behaviour, condition, domestic environment or associations of the child or of a person having care, custody, control or charge of the child;

(f) is subjected to aggression or sexual harassment that endangers the life, health or emotional well-being of the child;

(g) being under the age of 12 years, is left unattended and without reasonable provision being made for the supervision and safety of the child; or

(h) is the subject, or is about to become the subject, of an unlawful adoption under

The Adoption Act or of a sale under section 84 of the CFS Act.

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4. POLICY AND PROCEDURE STATEMENTS

Prevention

4.1 All new RFHS learners, staff and faculty members shall be familiarized with this Child Safeguarding and Protection Policy through their new faculty/staff/learner orientations.

4.2 For learners, staff or faculty members whose University of Manitoba work or University of Manitoba learning activities directly involve Children:

• A Criminal Records Check, Child Abuse Registry Check, and Adult Abuse Registry Check shall be required. For most learners, these Checks are a requirement on admission to, or registration in, the program. Therefore, please consult with the specific applicable program policy or regulation for additional detail;
• The Code of Conduct – Child Safeguarding and Protection (at Appendix A to this policy) is required to be read and the responsibilities of the individual acknowledged. Examples of activities that may directly involve Children include clinical learning/fieldwork activities, service-learning activities or training Children as standardized patients.

4.3 For research involving Children, please refer to the specific ethics requirements and processes applicable to the research project.

4.4 The requirements set out in section 4.2 are not applicable to group tours or other visits to RFHS facilities or affiliated sites where Children are present (such as “Take Our Kids to Work Day”) or other interactions where Children are present in a group setting (such as learner examination/invigilation where Children standardized patients are present but participating in a group setting; Children brought into a classroom or lab in a group setting).

Reporting

4.5 It is the legal responsibility and duty of anyone who reasonably believes that a Child is, or might be, In Need of Protection or suffering from Child Abuse, to report the information directly to a CFS agency. Reporting to other law enforcement authorities may also be required, if the suspected activity is criminal in nature. While a report of Child Abuse can result in an initial negative experience for the parties involved, reporting is both compulsory and necessary, as a Child’s life or safety may be at risk.

4.6 In addition to the mandatory reporting obligations as above noted, it may be necessary for the Child’s immediate safety to report the concerns to the parent(s) or guardian(s).

4.7 The duty to report supersedes any restrictions respecting the disclosure of information in legislation, including The Personal Health Information Act (Manitoba) or otherwise.

4.8 In addition to the mandatory reporting obligations under The CFS Act, suspicions or concerns about Child Abuse, a Child in Need of Protection, or other behaviour that might be considered inappropriate (refer to the Code of Conduct at Appendix A), require a report within the RFHS. The person making the mandatory CFS Act report shall inform their immediate supervisor (for learners this could be their preceptor, course/rotation/program director, Department Head, Associate Dean), as well as make a written report to the Dean and Vice-Provost of the RFHS, using the report form attached hereto at Appendix B (“Report Form”). If desired, the person’s immediate supervisor may assist in completing the Report Form.

4.9 Should an individual have any questions or require any guidance respecting the requirements to report, they should, in consultation with their immediate supervisor, access resources available to assist in decision making (such as Child and Family Services or RFHS resources) that have trained staff available to assist with decision making and with any parental communication and disclosure required.

4.10 Special Provision for Children’s Investment Fund Foundation (“CIFF”) Grants/Projects

In addition to the above reporting requirements, for CIFF grants or projects, the grantee must advise the local CIFF Designated Safeguarding Officer (“DSO”) or Program Manager, within three (3) days of knowledge of the concern or disclosure. Grantees are expected to provide regular updates to CIFF as to the status of any investigation and the outcome of the process, to the extent the Grantee is made aware of the status and outcome.

Investigation of a Faculty Member, Staff or Learner of the RFHS

4.11 If the respondent/offender is a faculty member, staff or learner of the RFHS, the Dean and Vice-Provost, RFHS will, upon receipt of a completed Report Form, ensure that an investigator (the “Investigator”) is assigned to review the report (“Report”) and ensure that all other mandatory reporting obligations as above noted are completed.

The Dean and Vice-Provost, RFHS may appoint either an employee of the University or an external consultant to act as the Investigator, provided that the Investigator:

• Has relevant skills and/or experience;
• Would be able to conduct an investigation in an unbiased manner; and
• Would not be placed in a conflict of interest.

4.12 Within 10 working days of being appointed, the Investigator ensures that the investigatory steps described below are completed. This may involve consultation with other units of the University about appropriate investigatory steps in accordance with applicable policies (e.g., Human Resources, Faculty of Graduate Studies). If the matter reported is being investigated by a law enforcement authority (e.g., under the CFS Act or Criminal Code of Canada), the Investigator may defer the University investigation to such other authority while also implementing measures to ensure the safety of work and learning environment in accordance with appropriate policies.

4.13 The Investigator will meet with the appropriate individuals to conduct an investigation and will inform senior leadership as required (e.g. Dean of the College, Associate Dean, Department Head, etc.) of the Report. The Investigator will conduct an investigation by interviewing the reporting individual, informing the respondent about the matter of the Report, interviewing the respondent, and interviewing any other persons who might have insight into the situation, such as witnesses and individuals in relevant positions. The Investigator may also conduct a joint investigation, including without limitation, with an affiliated clinical learning site, the Faculty of Graduate Studies, another Faculty, or the Office of Human Rights and Conflict Management. All such individuals will be bound to strict confidentiality regarding all aspects of the case.

4.14 The Investigator will review all of the information gathered in the course of the investigation and will submit their investigative report to the Dean and Vice-Provost, RFHS and the lead of any other applicable program or College (the “Dean/Director”) that includes the summary of the evidence and facts of the case and recommendations for action. If the matter has been deferred in lieu of investigation by a governmental authority, this should be reflected along with other interim measures that have been put into place. Once the other investigation is completed, this should also be reported, along with all findings. The Dean and Vice-Provost, RFHS will review the report and make a decision on the action to take, in consultation with the Dean/Director.

4.15 Actions resulting from a Report will depend on the circumstances, on the seriousness of the behaviour, whether the Report is determined to be founded or unfounded, on any mitigating factors and on applicable University policy, bylaw, collective agreement or academic regulation. The following list provides examples of measures and is not meant to be exhaustive nor necessarily represents a progression of measures:

• A letter of apology;
• Attendance at educational session(s);
• Attendance at coaching session(s);
• Prohibited or restricted access to Children;
• Academic consequences such as remediation, probation, notation on the performance record, dismissal/expulsion from the Program/College/RFHS, termination of academic appointment.

4.16 In cases where the respondent is dissatisfied with the decision, that person must submit his or her appeal in writing to the Dean and Vice-Provost, RFHS within 10 working days of the decision and refer to the applicable University Policy, Procedure or Bylaw or collective agreement.

Retaliation / Reprisal

4.17 A reporting individual, respondent, witness, and/or any other person who has sought advice regarding this Policy, who has brought forward allegations, who has made a report or who has cooperated with an investigation, is entitled to be supported and protected from retaliation and reprisal.

Retaliation or reprisal of any sort during or following the investigation is prohibited and will not be tolerated.

All concerns and complaints raised respecting retaliation or reprisal will be thoroughly reviewed and investigated, and any breaches appropriately addressed.

Accusations that retaliation or reprisal has occurred will be subject to investigation and may result in disciplinary action up to and including termination or expulsion.

4.18 There are many supports to assist in addressing one’s concerns about retaliation or reprisal. The University’s Office of Human Rights and Conflict Management is a resource available to all University members.

Faculty members and staff may contact Human Resources and their union representatives.

Learners may contact Student Affairs and Student Services at Bannatyne Campus representatives, including Student Advocacy.

If the individual is an employee in a certified bargaining unit, he or she may challenge a retaliation or reprisal, through the grievance process or applicable collective agreement.

A non-unionized employee may contact Human Resources.

A learner can challenge a retaliation or reprisal through an appeal process set out in the Student Discipline Bylaw, the academic appeal policy relating to their program, or other applicable discipline or academic appeal routes within the University.

4.19 False Accusations

Any RFHS faculty member, staff or learner found to have been dishonest in making allegations with a conscious design to mislead or deceive, or with a malicious or fraudulent intent may be subject to disciplinary action up to and including termination or expulsion.

Confidentiality and Record Keeping

4.20 Any communication of information gathered in any case is confidential. The RFHS will not disclose the name of the reporting individual, of the respondent, or the circumstances related to a report except to the extent that disclosure is necessary to effectively implement this policy or to undertake any disciplinary or action arising from a decision made under this policy. Records will be kept pursuant to any applicable relevant University policy and/or procedure.

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5. REFERENCES

5.1 Academic Regulations for graduate programs within the Rady Faculty of Health Sciences and its Colleges

5.2 Academic Regulations for undergraduate programs within the Rady Faculty of Health Sciences and its Colleges

5.3 Children’s Investment Fund Foundation Child Safeguarding and Protect ion Policy

5.4 Code of Conduct to Protect Children: Children’s Hospital Research Institute of Manitoba (in development)

5.5 Reporting of Child Protection and Child Abuse: Handbook and Protocols for Manitoba Service Providers

5.6 The Child and Family Services Act (Manitoba)

5.7 The Student Discipline Bylaw, University of Manitoba

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6. POLICY CONTACT

Please contact the Dean’s Office, Rady Faculty of Health Sciences, with questions regarding this policy.

Policy name	Disruption of all forms of racism
Application and scope	Staff, faculty members and learners of the Rady Faculty of Health Sciences and its colleges and programs
Approved date	August 25, 2020
Review date	Five (5) years from revised date
Revised date	November 21, 2023
Approved by	Executive Leadership Team, Rady Faculty of Health Sciences: October 11, 2023 Faculty Council, Rady Faculty of Health Sciences: November 21, 2023

1. BACKGROUND AND PURPOSE

1.1 Senator Murray Sinclair has defined systemic racism as “when the system itself is based upon and founded upon racist beliefs and philosophies and thinking that has put in place policies and practices.” The 2011 University of Manitoba Statement of Apology and Reconciliation to Indian Residential School Survivors recognizes the participation of the University in systemic racism both through its own structures and in its education and training of a workforce that participates in systems that also have deeply embedded racism.

In January 2022 the University of Manitoba became a signatory to the Scarborough National Charter on Anti-Black Racism and Black Inclusion in Canadian Higher Education. As part of the response to the United Nations’ International Decade for Peoples of African descent (2015–2024) the Charter recalls the distinct history of anti-Black racism on people of African descent in Canada. The University’s endorsement signals a formal commitment to addressing the persistent and pervasive impact of systemic anti-Blackness that remains embedded within Canadian post-secondary institutions. This is not less true today when we think of the pervasive impacts of racism in many systems including health care.

1.2 Existing University of Manitoba policies including the Prevention of Learner Mistreatment Policy (PLM, Max Rady College of Medicine), the Responsibilities of Academic Staff with Regard to Students Policy, the Equity, Diversity, and Inclusion Policy (EDI, Rady Faculty of Health Sciences), the Respectful Work and Learning Environment (RWLE) Policy, the Violent or Threatening Behaviour Policy, the Student Non-Academic Misconduct and Concerning Behaviour Procedure, the Student Discipline Bylaw and the Sexual Violence Policy, do not communicate an adequate understanding of the politics of race and the significance of racism as it pertains to Black, Indigenous, and racialized minority learners, staff and faculty. If a policy does not take race into account in a meaningful way, then racism can remain “invisible” or can be deemed to be nonexistent and therefore allowed to persist and potentially increase. This Policy constitutes a formal recognition of racial harassment, racial discrimination, racial vilification, and racism. It is an affirmation of a) the histories of dispossession, enslavement, genocide, and their legacies; b) ongoing settler colonial projects; and c) the humanity, rights, dignity, and safety of Black, Indigenous, and racialized minority learners, staff, and faculty.

1.3 The purpose of this policy is to:

(a) Define the multiple forms of racism that are present in the Rady Faculty of Health Sciences (“RFHS”) and to set out procedures for the reporting of and disruption of racism.

(b) Affirm the responsibility of the RFHS to implement policies, procedures, education, and training to eliminate expression of racism in its myriad forms.

(c) Describe the commitments and proactive steps of the RFHS to foster learning and work environments that fully respect peoples’ right to freedom from racism, racial discrimination, racial harassment, or racial vilification.

(d) Set out the requirements for all RFHS Community members, especially those in an instructional, supervisory or managerial position, who have a duty to educate those for whom they are responsible regarding expectations for respectful conduct, including this Policy. It is further the duty of such individuals to intervene when observing any form of racism impacting learners, staff, or faculty, and to deal appropriately with allegations regarding violations of this Policy.

(e) Set out a fair and consistent process for responding to Disclosures, and/or Formal Complaints of Racial Harassment, Racial Discrimination, Racial Vilification, Racism or Reprisal that ensures that all RFHS Community Members will be treated with dignity, respect, and compassion.

(f) Complement and build upon related policies including the EDI Policy, RWLE Policy, and PLM Policy by defining the multiple forms of racism present within the RFHS and clarifying expectations for anti-racism behaviour and actions in the RFHS.

1.4 More information on the context and background of this Policy is available on the RFHS Office of Anti-Racism website.

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2. DEFINITIONS

2.1 The terms in this Definition section are defined for the purposes of this Policy:

(a) “Academic Staff” refers to all individuals whose primary assignment is instruction, research, and/or service/academic administration. This includes employees who hold an academic rank such as professor, associate professor, assistant professor, instructor, lecturer, librarian, or the equivalent of any of those academic ranks. This category also includes a dean, director, associate dean, assistant dean, chair, or head of department, visiting scholars, senior scholars, and those holding unpaid academic appointments, insofar as they perform instructional, research, and/or service/academic administrative duties.

(b) “Breach” means any conduct, behaviour, action, or omission that is prohibited under the Disruption of All Forms of Racism Policy, including but not limited to Racial Harassment, Racial Discrimination, Racial Vilification, Racism, Reprisals, and Retaliation.

(c) “Complainant” means the individual or individuals bringing forward a Formal Complaint of a Breach.

(d) “Disclosure” means telling someone about an instance of racial harassment, racial discrimination, racial vilification, or racism. For the purpose of this Policy and the Procedures, a disclosure means telling someone as outlined in section 3.5 of this Policy. A Disclosure does not initiate an Investigation unless a Formal Complaint is made, or the University initiates an Investigation in accordance with the Procedure.

(e) “Faculty Member” means all unionized and non-unionized academic staff of the RFHS, visiting professors, clinicians with academic appointments and including academic staff whose salary or stipend may be paid, in whole or in part, by another organization.

(f) “Formal Complaint” means a complaint to the Office of Anti-Racism, the Office of Professionalism, or the Office of Human Rights and Conflict Management that is in writing and contains, at minimum, the following:

• The name of the Complainant and contact information for the Complainant;
• A description of the alleged Breach;
• The approximate date of the alleged Breach;
• The name of the Respondent;
• Contact information of the Respondent, if known; and
• An indication that the Complainant desires the Formal Complaint to be the subject of an Investigation.

(g) “Immediate Measures” are non-disciplinary measures that may be imposed where there is reasonable cause to believe that such arrangements are necessary in order to protect the safety of the learning and working environment, discourage or prevent Reprisal, prevent further incidents, or preserve the University’s ability to conduct a fair investigation. Where circumstances are urgent, or expeditious safety measures are required, Immediate Measures may be imposed prior to the submission of a Formal Complaint. Immediate measures are not based on a finding of a Breach of the policy, are not considered sanctions under any University complaint process, and may not be interpreted or used in a complaint as evidence that the person under the allegation committed misconduct. Immediate Measures may be applied in response to a Disclosure or a Formal Complaint.

(h) “Informal Resolution” means the resolution of an alleged Breach to the satisfaction of the Complainant and the Respondent without an Investigation being completed.

(i) “Intersectionality” refers to the ways that racism, racial discrimination, racial harassment, and racial vilification are frequently linked/shaped/informed by other elements of identity such as sex, gender identity and expression, class, (dis)ability, and sexuality. Intersectionality disrupts either/or frameworks by offering a lens to represent how different forms of inequality work together and aggravate each other by describing how the various elements of our identities result in some people experiencing multiple oppressions and inequalities simultaneously.

(j) “Investigation” means a formal investigation of an alleged Breach conducted in accordance with the Procedure.

(k) “Learner” means an individual registered at the University, within a program of the RFHS, or one of its Colleges, on a full-time or part-time basis, or as a special student. A Learner can be at the undergraduate, graduate, or postdoctoral level, and includes medical students, non-professional graduate students, residents, and fellows and individuals registered at another institution, but attending the RFHS on a temporary basis as part of an elective or similar program.

(l) “Racialized” refers to the processes in and through which groups are identified as being a member of a particular race, and subsequently subject to distinct and/or disparate treatment. Racialization is the process through which groups are socially constructed as races according to traits such as phenotype, religion, culture, economics, etc. The concept of racialized locates race as a social and historical construct and takes in to account the fact that racial meanings are dynamic, shaped by the political, economic, and social conditions in which they appear. Processes of racialization include everyone in the system of racial categorization, not simply those typically identified as “raced,” or those commonly identified as “non-white.” E.g., individuals and/or groups are also racialized - as white. Recognition of how we are all racialized, engendered, and sexualized (to name some elements of our identities) makes explicit the existence and organization of racial hierarchies. In sum, to only identify members of Black, Indigenous, and racialized minority communities as “raced,” excludes whiteness from the racial order, because it fails to identify the racialization processes assigned to people of European ancestry .

• (i) “Racia(lized) minority” refers to groups of people that share historical and cultural experiences of discrimination, stereotyping, and prejudice, and who are marginalized because they may have negligible, or no access to religious, economic, or social power. Hence, the word minority does not refer to a number or percentage, but to experience.
• (ii) “Racial(ized) majority” refers to processes of racialization assigned to people of European descent.

(m) “Racism” is the differential treatment of various human racial groups by a dominant racial group rooted in the belief of the superiority of one group over the other. Racism takes many forms, some of which include symbolic, embodied, psychological, institutional/systemic, everyday, and interpersonal. Experiences of racial discrimination, harassment and vilification can be affected by its intersection with other elements of identity such as sex-gender, sexuality, disability, faith/spirituality, and age. The following definitions of different forms of racism are illustrative and not exhaustive. Additional definitions can be found on the RFHS Office of Anti-Racism website.

• “Anti-Indigenous Racism” refers to the unique nature of prejudice, stereotyping, violence, injustice, and discrimination experienced by Indigenous peoples in Canada. It highlights the history of genocide, dispossession, and settler colonial policies and practices in Canadian institutions and their enduring legacies. Systemic manifestations of anti-Indigenous racism(s) are exhibited in Federal and Provincial policies such as the Indian Act, the Residential School System, child welfare, and criminal justice systems. Anti-Indigenous racism is also manifest in inequitable outcomes in health, education, and in the disproportionate rates of violence against Indigenous women, girls and 2SLGBTQQIA+ people.
• “Anti-Black Racism” refers to the stereotyping, attitudes, prejudice, and discrimination aimed at people of African descent. It draws attention to the history of enslavement and colonization and their legacies and emphasizes the particular character of systemic racism directed towards Black people that is manifest in policies and practices embedded in Canadian institutions such as health care, education, employment, and the criminal justice system. Incorporating the concept of intersectionality, anti-Black racism also recognizes the diversity and complexity of Black peoples, including Black peoples across the gender spectrum, Black persons with disabilities, and Black peoples in LGBTQQIA+ communities (e.g., anti-Black gendered racism, anti-Black homophobia etc.).
• “Everyday Racism” refers to the “mundane” elements of everyday life that are typically not recognized because these manifestations of racism have become so normalized that they are typically not identified as racism. Everyday racism refers to tone, language, a gaze, forms of surveillance (in public spaces), differential treatment/service (being ignored in the learning/clinical environment, denying the reality of a Black, Indigenous, or racialized minority person, or the expectation that one can speak for all members of a racialized minority group) and actions such as moving when an Indigenous, Black, or racialized minority student is seated beside a person on the bus or in the classroom. Everyday racism is multidimensional, and its impact is cumulative.
• “Gendered Racism” refers to the allocation of resources along racially and ethnically ascribed understandings of masculinity and femininity as well as along gendered forms of race and ethnic discrimination.
• “Interpersonal Racism” refers to attitudes, ideas, and behaviours that support, and therefore reinforce, racial inequality. It is important to note that interpersonal and institutional racism function both independently and in concert.
• “Systemic/Institutional Racism” refers to the arrangements and practices that maintain racial hierarchies and racial inequality. It comprises policies, behaviours and practices that are part of the social, cultural, or administrative elements of an organization and which produce or maintain positions of disadvantage for racialized minority individuals.
• “Racial Discrimination” refers to behavior that impedes and disadvantages people, by withholding benefits, opportunities due to their perceived race, colour, nationality, ethnicity, ethno-religious or national origin.
• “Racial Harassment” refers to an incident or a series of incidents having the effect of intimidating, offending, or harming an individual or group because of their perceived ethnic origin, race or nationality. This includes verbal and/or physical abuse, insults and name-calling, bullying, threatening behaviour, damage to property, displaying and/or sharing racially offensive material and encouraging others to commit racist acts.
• “Racial Microaggressions” are everyday slights, indignities, put downs and insults that Black, Indigenous, or racialized minority individuals experience in their day-to-day interactions with people. They can consist of racial microassaults (often said privately), racial microinsults (e.g., demeaning of racial identity) and racial microinvalidations (e.g., “I don’t see colour”).
• “Racial Vilification” refers to a public act that inspires or provokes others to hate, have disrespect, or ruthlessly deride a person or group of people due to their perceived race, colour, nationality, ethnicity or ethno-religious or national origin.

(n) “Reprisal and Retaliation” means any measures taken against a Complainant, Respondent, or any other person because they have asked for advice regarding this Policy or Procedure, brought forward allegations of a Breach or made a Formal Complaint, or cooperated with an Investigation and when learners report patient related incidents of racism. Reprisal and Retaliation measures include, but are not limited to:

• Discipline;
• Academic Penalties (in the case of learners);
• Not working with specific staff (in the context of residency education and medicine);
• Demotion;
• Termination of employment;
• Termination of academic employment;
• Non-standardized metrics such as reference letters and monthly performance evaluations;
• Any other measure which significantly adversely affects working conditions or educational experience; and
• A threat to take any of the measures referred to above.

(o) “Respondent” means an individual or individuals accused of having caused or contributed to a Breach.

(p) “RFHS Community” means all RFHS members including Faculty/College/School Councils, employees, anyone holding an appointment with the RFHS, Learners, volunteers, external parties, contractors, and suppliers.

(q) “RFHS Matter” means any activity, event, or undertaking in which a member of the RFHS Community participates, which has a substantial connection to the RFHS, such as:

• RFHS-related activities or events, including but not limited to:
  • Any activity or event on property owned or controlled by the RFHS;
  • Learner placements, practica, or clinical training;
  • RFHS research activities, whether on or off campus;
  • Learner and/or employee exchanges arranged in connection with the RFHS;
  • Social events or networking, where matters regarding the RFHS or members of the RFHS Community are a significant focus of the activity;
  • RFHS field trips, travel-study tours, service-learning activities, and similar activities.
• Activities or events involving members of the RFHS Community, where the actions of those members of the RFHS Community may reasonably reflect upon or affect the RFHS, including but not limited to:
  • Any aspect of the employment or engagement of employees and contractors for roles and projects substantially connected to the RFHS;
  • Writings, photographs, artwork, audio or video recordings, and/or electronic communications, including communications through social media, where matters regarding the RFHS Community are a significant focus of the communication;
  • Matters related to The University of Manitoba Students’ Union, the Graduate Students’ Association, and their affiliated Learner groups to the extent that it affects the proper functioning of the RFHS or the rights of a member of the RFHS Community to use and enjoy the RFHS’s learning and working environments; or
  • Matters of off-campus conduct that have, or might reasonably be seen to have, an adverse effect on the proper functioning of the RFHS or the rights of a member of the RFHS Community to use and enjoy the RFHS’s learning and working environments.

(r) “Third Party Reporting” refers to a form of anonymous reporting where someone who has experienced racism can report it through someone else (described further below) who then accesses one of the established reporting mechanisms to report the experience.

(s) “Racial Equity Impact Assessment” (REIA) is a systematic examination of how different racial and ethnic groups will likely be affected by a proposed action or decision. REIAs are used to minimize unanticipated adverse consequences in a variety of contexts, including the analysis of proposed policies, institutional practices, programs, plans and budgetary decisions.

Responsibilities of the Rady Faculty and university community

Rady Commitments

2.2 The RFHS is committed to fostering learning and work environments that fully respect peoples’ right to freedom from racism, racial discrimination, racial harassment, or racial vilification. The RFHS is therefore committed to:

(a) Making available and actively promoting materials/resources/activities to support members of the RFHS Community in their efforts to understand and address racism, racial discrimination, racial harassment, or racial vilification;

(b) Encouraging individuals to bring concerns about an alleged Breach to an appropriate authority, and protecting those who bring forward such allegations against Reprisal;

(c) Supporting those impacted by racism, racial discrimination, racial harassment, or racial vilification through academic, nonacademic, workplace, and other supports or accommodations as required;

(d) Ensuring a trauma-informed and Intersectional approach to the implementation of this Policy and the Procedure;

(e) Ensuring barriers to the application of this Policy are reduced, including that individuals will not be asked to repeat their accounts more than is necessary for the implementation of this Policy or the Procedure;

(f) Ensuring that following a Disclosure, or a Formal Complaint of racism, racial discrimination, racial harassment, or racial vilification, all University Community members are treated with compassion, dignity and respect, and provided with support throughout the process;

(g) Responding to racism, racial discrimination, harassment, or vilification in a manner that minimizes traumatization or retraumatization, and promotes recovery, empowerment, and self-determination, subject to the limits of confidentiality and the RFHS’s community safety obligations as set out in this Policy and the Procedure.

(h) Respecting the privacy of those impacted by racism, racial discrimination, racial harassment, or racial vilification in accordance with the Procedure;

(i) Implementing appropriate immediate measures that ensure fairness;

(j) Monitoring and updating University Policies and protocols to ensure that they remain effective and in line with other existing Policies and best practices; and

(k) Implementing this Policy and the Procedure with transparency and accountability, including applying this Policy to all members of the RFHS Community regardless of a person’s social position, or position with the University structures or hierarchies.

RADY COMMUNITY RESPONSIBILITIES

2.3 Fostering learning and work environments that fully respect peoples’ right to freedom from racism, racial discrimination, racial harassment, or racial vilification is a responsibility of all members of the RFHS. The Faculty calls for all members of the University community, especially those in instructional, supervisory, or managerial positions to:

(a) Bring forward evidence of a Breach of which they become aware to the Office of Anti-Racism;

(b) Deal appropriately with allegations regarding Breaches or other violations of this Policy or Procedure;

(c) Provide reasonable cooperation in an Investigation of a Breach;

(d) Be aware of their responsibilities and educate themselves as to the expectations and reporting requirements under this Policy and the Procedure; and;

(e) Educate those for whom they are responsible regarding expectations for safe and respectful conduct, including this Policy and Procedure.

Education, training and support

2.4 Education is a fundamental aspect of the University’s commitment to preventing and addressing racism, racial discrimination, racial harassment, or racial vilification. The RFHS will provide access to coordinated education and resources pertaining to responding to, and raising awareness about racism, racial discrimination, racial harassment, or racial vilification. Proactive measures that will be taken by the RFHS will be grounded in the Guiding Principles of this Policy, and include implementing and actively promoting education, awareness, and racial literacy, in multiple fully accessible formats and tailored to multiple audiences.

Autonomy in disclosure and/or formal complaints

2.5 A person who has made a Disclosure and/or Formal Complaint of racism, racial discrimination, racial harassment, or racial vilification has autonomy in decision-making, and in particular with respect to whom to disclose, whether to make a Formal Complaint, whether to pursue recourse to the criminal or civil justice systems, and whether to access available supports and accommodations.

2.6 Notwithstanding section 2.5, there are exceptions, as the University also has an obligation to protect the University community from harm. The University reserves the right to initiate a University Instituted Investigation in accordance with the Procedure, and/or to report the incident to local police services, even without the consent of the Complainant, if it is believed that the safety of the University Community is at risk. In cases where actions are taken without the consent of the Complainant, reasonable efforts will be made to preserve the anonymity of the Complainant. In addition, the Complainant will be notified of the actions the University intends to take in order that the Complainant can work with the University to take any additional safety precautions that may be required as a result of the University’s actions.

Annual report

2.7 The Office of Anti-Racism will produce and provide an annual report to the Vice-Dean of Indigenous Health, Social Justice, and Anti-Racism outlining:

(a) Information on activities undertaken to raise awareness and contribute to organizational change, including the type of activity and the number of students and staff who attend;

(b) De-identified data regarding the number and types of Disclosures and Formal Complaints received;

(c) De-identified data on fairness factors such as time to process and the identity of investigators;

(d) Information regarding observable trends and commentary on the implementation and effectiveness of the Policy; and

(e) Other relevant information which may further the implementation of the Policy and its Procedure.

(f) The annual report will be made available to the RFHS University Community.

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3. POLICY AND PROCEDURE STATEMENTS

3.1 The RFHS is committed to taking the necessary steps to ensure that no RFHS Community member is subjected to Racism, Racial Discrimination, Racial Vilification, and Racial Harassment while participating at the RFHS and to interrupt and address Racial Violence when it is identified.

3.2 This Policy applies to members of the RFHS Community in relation to any RFHS Matter.

3.3 Examples of Racism include, but are not limited to the following actions which the person experiencing them believes are based on perceived race, colour, nationality, ethnicity, ethno-religious (e.g. anti-Semitism or Islamophobia) or national origin of an individual or group:

Interpersonal

(1) Racial stereotyping or racial profiling of individuals on campus.

(2) Subjecting an individual to racially or ethnically offensive remarks, names, slurs, racial epithets, or jokes.

(3) Singling out an individual for teasing, comments, or jokes related to race, ancestry, place of origin, or ethnic origin.

(4) Circulating racially offensive jokes, pictures, comments, or cartoons by email/social media.

(5) Comments ridiculing individuals because of race-related characteristics, religious dress, or iconography.

(6) Failing to deal with racial incidents or downplaying the seriousness of such conduct e.g., “that was not their intent,” “they were joking,” “I am not racist,” “I am a good person.”

(7) Characterizing normal communication from Black, Indigenous, and racialized minority learners, staff, and faculty as rude, hostile, or aggressive.

(8) Treating normal differences of opinion as confrontational or insubordinate when involved with Black, Indigenous, and racialized minority persons.

(9) Treating Black, Indigenous, and racialized minority individuals’ responses to racial incidents or bullying as a disciplinary problem without dealing with the underlying incident or considering the underlying incident as a mitigating factor.

(10) Differential disciplinary action for Black, Indigenous, or racialized minority individuals vs. members of the racial(ized) majority.

(11) Racist graffiti.

(12) Penalizing a person for failing to get along with someone else (e.g., colleague, manager, fellow learner), when one of the reasons for the tension is racially discriminatory attitudes or behaviour.

(13) Using a racial epithet.

(14) Disparaging an individual based on their race.

(15) Attributing the same characteristics to all members of a group, regardless of individual differences.

(16) Failing to hire, train, mentor or promote a racialized minority person. Racialized minority persons may find themselves subjected to excessive performance monitoring and documentation or deviation from written policies or standard practices or may be more seriously blamed for a common mistake.

(17) Normal differences of opinion or failing to get along with a co-worker/colleague/learner may be treated as more serious when a racialized minority person is involved.

(18) Contrasting how a racialized minority person was treated with how others were treated in a comparable situation.

(19) A non-existent contradictory or changing explanation for why a racialized minority person was targeted.

(20) Denial of mentoring or developmental opportunities and training which were made available to others.

(21) Subjecting Black, Indigenous, or racialized minority individuals to threatening gestures. Verbally abusing, belittling, insulting, ridiculing or yelling or speaking in a sarcastic manner in public or private.

(22) Assigning Black, Indigenous, or racialized minority individuals less desirable positions or duties or assigning duties as punishment rather than education.

(23) Disproportionate blame for an incident or singling out a Black, Indigenous, or racialized minority individual for arbitrary treatment that is punitive.

(24) Belief in the inherent superiority of one racial group, over another, through actions or criticism conducted in public that can be interpreted as embarrassing, humiliating, and/or demeaning.

(25) Incident or a series of incidents having the effect of intimidating, offending or harming a Black, Indigenous, or racialized minority individual or group.

(26) Exclusion from formal or informal networks or opportunities. Neglecting or leaving a Black, Indigenous, or racialized minority individual out of the communication thread.

(27) Not providing racialized minority individuals with clear work/learning expectations yet holding them responsible for the expectations.

(28) Committing an act of physical abuse or violence of any kind (e.g., throwing objects, aggressive violation of personal space) against a Black, Indigenous, or racialized minority individual.

(29) Making unwelcome sexual comments, jokes, innuendos, or taunting remarks about sexuality, gender identity, and expression.

(30) Using grades/poor reviews as punishment rather than as an objective evaluation of performance.

(31) Threatening to fail, give lower grades, poor performance review or give a poor evaluation for anything other than documented performance issues.

(32) Looks of contempt/hate.

(33) Subjecting an individual to inappropriate references to racist organizations.

Systemic/institutional

(34) Not allowing for time off for religious or spiritual practices other than Christian holidays.

(35) Differential career trajectories, opportunities (e.g., time to promotion and/ or tenure) for different Black, Indigenous, or racialized minority populations.

(36) Patterned exclusion from formal or informal networks, thereby providing advantages to the racial(ized) majority while disadvantaging others.

(37) Application of differential practices such as excessive monitoring, documentation, and performance assessments, or deviation from written policies or standard practices to Black, Indigenous, or racialized minority populations.

(38) Differential disciplinary action for Black, Indigenous, or racialized minority populations.

(39) Disproportionate blame for an incident on Black, Indigenous, or racialized minority populations.

(40) Unequal opportunity for employment related to hiring practices, union rules around seniority.

(41) Failing to deal with racial incidents or downplaying the seriousness of such conduct (e.g., “that was not their intent”).

3.4 All new policies, procedures, and programs, and, at the time of their review, all existing policies, procedures and programs, of the RFHS and its member Colleges will undergo a Racial Equity Impact Assessment (REIA) to identify any potential elements of systemic/institutional racism and propose mitigating measures. These REIAs will be done by the person/committee responsible for the policy, procedure, or program in partnership with the Anti-Racism Expert Working/Advisory Group and submitted with the draft policy, procedure, or program to the appropriate College or Faculty decision-making body.

3.5 “No Wrong Door” disclosing of experiences of Racism. For members of the RFHS, this approach centers the needs of the person(s) who has experienced Racism, and is trauma- and violence-informed in its processes. The procedures for a directly ordered informal review, or formal investigation and remediation/resolution of experiences of racism may rely on existing mechanisms, or may proceed according to procedures set out in the accompanying Anti-Racism Guidelines and Processes for Disclosure and Reporting Document. This will be enhanced with the participation of individuals with specific anti-racism expertise, for example, the individual can request a Black, Indigenous, or racialized minority person as a support to accompany them throughout the Complaint process.

3.6 Existing potential mechanisms to report and address experiences of Racism that have procedures detailed in other related or relevant policies and include:

(a) The Speak Up button (anonymous or non-anonymous reporting) and the Max Rady College of Medicine Prevention of Learner Mistreatment Policy and the RFHS Prevention of Learner Mistreatment Guideline.

(b) Report to a manager, supervisor, course leader, Department Head, Dean, or other trusted Academic Staff or Faculty Member who is expected to provide the person(s) with options for formal or informal reporting;

(c) Report to the Office of Human Rights and Conflict Management;

(d) Report to the Office or Associate Dean of Professionalism (currently Medicine only).

3.7 Nothing in this Policy is intended to discourage or prevent a member of the RFHS Community from filing a complaint with the Manitoba Human Rights Commission, professional regulatory bodies, or from exercising any other legal rights pursuant to any other law or policy.

3.8 In addition to the existing potential reporting mechanisms, breaches of this Policy can be reported through a third party(ies). Third Party Reporting can be an important procedure to address under-reporting of racism. Third Party Reporting offers the option of reporting the details of an experience or experiences of racism anonymously when individuals are not ready or willing to participate in an investigation because of the risk of reprisal or further racial violence. Third Party reporting may result in a directly ordered informal review, a Racial Equity Impact Assessment, or remediation/resolution of experiences of racism may rely on existing mechanisms, or may proceed according to procedures set out in the accompanying Anti-Racism Procedure Document.

3.9 Disciplinary options may be limited for breaches of this Policy reported anonymously or using Third Party reporting where that results in the unavailability of sufficient information. This does not preclude remedial action based on the information available or disciplinary action where the information available is sufficient or where a previous pattern of behaviour has been established through previous reporting (anonymous or non-anonymous).

3.10 When any form of Racism occurs and is reported, remedial measures will depend on multiple factors including the input of the person(s) who experienced the Racism (e.g. they have the right to determine the path/course of action, namely whether the complaint is formal or informal, and through what process the complaint is made), the circumstances, the seriousness of the behaviour, the frequency or duration of the behaviour, any mitigating factors and applicable University policy, bylaw, collective agreement or academic regulation. The following list provides examples of remedial measures and is not meant to be exhaustive or necessarily represent a progression of measures:

• Attendance at educational sessions on antiracism with evidence of reflective learning;
• A restorative justice-based approach to mediation when all parties are willing;
• Prohibited or restricted access to the work or learning environment;
• Academic consequences such as remediation, probation, notation on the performance record, dismissal/expulsion from the program of the RFHS/its College, termination of the academic appointment;
• Disciplinary consequences according to applicable policies and procedures for Faculty Members and staff;
• Reporting to legal authorities if the actions represent a potential violation of the Canadian Criminal Code.

3.11 “Protection from Reprisal, Retaliation, or Threats”

• A Complainant, Respondent, witness, and/or any other person who has sought advice regarding the Disruption of All Forms of Racism Policy, who has brought forward allegations of a Breach, who has made a Formal Complaint, who has cooperated with an Investigation, is entitled to be protected from Reprisal, Retaliation or Threats. An individual may complain about an alleged Reprisal, Retaliation, or Threat to the Investigator, the Office of Professionalism, the Office of Anti-Racism, or to the OHRCM.
• Upon observing or being notified of an alleged Reprisal, Retaliation, or Threat the Investigator may:
  • (a) Investigate and include in their Investigation Report information relating to the alleged Reprisal, Retaliation, or Threat; and
  • (b) If the matter is urgent, refer the information regarding an alleged Reprisal, Retaliation, or Threat to the Office overseeing the investigation (which may be the Office of Anti-Racism, the Office of Professionalism, or OHRCM).
• Where the Investigator refers an urgent allegation of Reprisal to the Office of Anti-Racism, Office of Professionalism, or OHRCM, the person responsible will advise any such persons as believed necessary to discuss and implement Immediate Measures.
• Notwithstanding the definition of Reprisal, Retaliation, or Threat at section 2.1(k) of this Policy, it is not a Reprisal or Retaliation for the University to implement discipline or take other measures against an individual if:
  • (a) The individual has interfered or attempted to interfere with an Investigation;
  • (b) The person made a Formal Complaint or allegations in bad faith;
  • (c) The individual has materially breached the Disruption of All Forms of Racism Policy;
  • (d) Discipline is otherwise warranted against the individual under applicable legislation or common law, or University policies, procedures, or bylaws.

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4. REVIEW AND EFFECT ON PREVIOUS STATEMENTS

4.1 The review date this Policy and Procedure is five (5) years from the date it is approved by the approving body. In the interim, this document may be revised or repealed if:

(a) The Dean, RFHS & Vice-Provost (Health Sciences), with appropriate approvals, deems it necessary or desirable to do so;

(b) It is no longer legislatively or statutorily compliant; and/or

(c) It comes into conflict with another governing document of the RFHS or the University of Manitoba.

4.2 If this document is revised or repealed, any related RFHS documents shall be reviewed as soon as possible to ensure that they comply with the revised document, or, are in term revised, or repealed.

4.3 This Policy supersedes all previous governing documents dealing with the subject matter addressed in this document.

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5. REFERENCES

This policy should be cross-reference to the following relevant governing documents, legislations and forms:

5.1 The Human Rights Code, C.C.S.M. c. H175;

5.2 The International Convention on the Elimination of all Forms of Racial Discrimination;

5.3 The Max Rady College of Medicine Prevention of Learner Mistreatment Policy;

5.4 The United Nations Declaration on the Rights of Indigenous Peoples;

5.5 The University of Manitoba Respectful Work and Learning Environment (RWLE) Policy;

5.6 The University of Manitoba Disclosures and Complaints Procedure;

5.7 The University of Manitoba Responsibilities of Academic Staff with Regard to Students Policy and Procedure;

5.8 The University of Manitoba Sexual Violence Policy;

5.9 The University of Manitoba Violent or Threatening Behaviour Policy and Procedure;

5.10 The University of Manitoba Student Discipline Bylaw and Procedure.

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6. SOURCES

6.1 Alberta Civil Liberties Research Centre Glossary

6.2 Alexander, C., & Knowles, C. (2005). Introduction. In C. Alexander, & C. Knowles (Eds.), Making race matter: Bodies, space and identity (pp. 1-16). New York, NY: Palgrave Macmillan.

6.3 Andersen, M. L. (2020). Getting smart about race. Lanham, MD: Rowman & Littlefield.

6.4 Black Health Alliance. (2018).

6.5 Crenshaw, K. W. (1994). Mapping the margins: Intersectionality, identity politics, and violence against women of color. In M. A. Fineman (Ed.), The public nature of private violence: women and the discovery of abuse (pp. 93-120). New York, NY: Routledge.

6.6 Delgado, R., & Stefancic, J. (2017). Critical race theory: An introduction. New York, NY: New York University Press.

6.7 Essed, P. (2002). Everyday racism: A new approach to the study of racism. In P. Essed, & D. T. Goldberg (Eds.), Race critical theories: Text and context (pp. 176-194). Malden, MA: Blackwell.

6.8 Essed, P. (n. d.). Towards a methodology to identify converging forms of everyday discrimination.

6.9 Hall, S. (1996). Race the floating signifier. The Media Education Foundation.

6.10 Kendi, I. (2016). Stamped From the Beginning: the definitive history of racist ideas in America. New York, NY: Nation Books.

6.11 Matsuda, M. J., Lawrence III, C. R., Delgado, R., Words, & Crenshaw, K. W. (1993). Words that wound: Critical race theory, assaultive speech, and the First Amendment. New York, NY: Routledge.

6.12 Ontario Human Rights Commission: Appendix 1: Glossary of human rights terms.

6.13 Reclaiming Power and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls. (2019). Volume 1 b.

6.14 Scarborough National Charter on Anti-Black Racism and Black Inclusion in Canadian Higher Education: Principles, actions, and accountabilities (2022).

6.15 Steinmetz, K. (February 20, 2020). “She coined the term ‘intersectionality’ over 30 years ago. Here’s what it means to her today.” Time magazine.

6.16 Truth and Reconciliation Commission of Canada: Calls to Action (2015).

6.17 United Nations: International Convention on the Elimination of All Forms of Racial Discrimination (1969).

6.18 United Nations: Declaration on the Rights of Indigenous Peoples (2007).

6.19 United Nations. Report of the Working Group of Experts on People of African Descent on its Mission to Canada (2017).

6.20 University of Alberta Reporting Options for Survivors of Sexual and Gender Based Violence. (2023).

6.21 Wing Sue, D., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271-286.

6.22 Working Glossary. Addressing Racism: An Independent Investigation into Indigenous-Specific Discrimination in B.C. Health Care (2020).

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7. POLICY CONTACT

Please contact The Rady Office of Anti-Racism, RFHS, with questions regarding this document.

Policy name	Equity, diversity and inclusion
Application and scope	Staff, faculty members and learners of the Rady Faculty of Health Sciences and its colleges and programs
Approved date	February 4, 2020
Review date	Five (5) years from approval date
Revised date
Approved by	Dean’s Council, Rady Faculty of Health Sciences: January 21, 2020 / Faculty Executive Council, Rady Faculty of Health Sciences: February 4, 2020

 

1. PREAMBLE AND COMMITMENT

1.1 On January 26, 2018 (revised January 21, 2020), the Rady Faculty of Health Sciences (“RFHS”) and its Colleges of Dentistry, Medicine, Nursing, Pharmacy and Rehabilitation Sciences (collectively, the “Colleges”) agreed upon a joint commitment of Equity, Diversity and Inclusion (also referred to herein as “EDI”) which included the commitment of ensuring that its learners, faculty, and staff are reflective of the population served.

1.2 The RFHS wishes to set out its commitment to EDI into policy form, in an effort to promote and support a community that embraces EDI, provides for equality of opportunity and recognizes the dignity of all people.

1.3 The RFHS acknowledges its location on Treaty 1 Territory, acknowledges its obligation to provide service to diverse Indigenous communities and is committed to implementing the Calls to Action and Principles of Reconciliation issued by the Truth and Reconciliation Commission of Canada (“TRC”). In furtherance of this commitment, the RFHS pledges to work with Ongomiizwin, the Indigenous Institute of Health and Healing, in accordance with the RFHS Reconciliation Action Plan, led by Ongomiizwin.

1.4 Equity, Diversity and Inclusion are linked to all five University of Manitoba’s Strategic priorities:

1. Inspiring Minds through innovating and quality teaching;
2. Driving Discovery and Insight through excellence in research, scholarly work and other creative activities;
3. Creating Pathways to Indigenous Achievement;
4. Building Community that creates an outstanding learning and working environment; and
5. Forging Connections to foster high impact community engagement that build on the advantages of a diverse and inclusive workplace.

1.5 Equity, Diversity and Inclusion align with the RFHS’ shared set of values in community and collaboration, scholarship and innovation, equity and inclusion, professionalism and social accountability.

1.6 Learners, faculty and staff are to be free from harassment and discrimination, as defined in The Human Rights Code (Manitoba) and in accordance with the University of Manitoba’s Respectful Work and Learning Environment (RWLE) Policy. That is, all Learners, faculty and staff, regardless of race, ethnicity, colour, religious beliefs, national origin, rurality, gender, age, sexual orientation, disability, political beliefs, language, or socio-economic status, are to be valued for their individuality, advanced academic pursuits, and contributions to the diversity and functions of the RFHS and the University of Manitoba. Unacceptable discrimination, including racism, micro aggressions, sexism, ableism, ageism, homophobia and transphobia will not be tolerated. An RFHS Anti-Racism policy is currently in development.

1.7 Learners, faculty and staff are to be free from harassment and discrimination, as defined in The Human Rights Code (Manitoba) and in accordance with the University of Manitoba’s Respectful Work and Learning Environment (RWLE) Policy. That is, all Learners, faculty and staff, regardless of race, ethnicity, colour, religious beliefs, national origin, rurality, gender, age, sexual orientation, disability, political beliefs, language or socio-economic status, are to be valued for their individuality, advanced academic pursuits, and contributions to the diversity and functions of the RFHS and the University of Manitoba. Unacceptable discrimination, including racism, micro aggressions, sexism, ableism, ageism, homophobia and transphobia will not be tolerated. An RFHS Anti-Racism policy is currently in development.

Learners, faculty or staff found to have engaged in such conduct will be counselled, warned or disciplined. Severe or repeated breaches will lead to formal discipline up to and including leave without pay or dismissal.

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2. PURPOSE

2.1 To set out the minimum principle-based requirements to be implemented by the RFHS and its member Colleges in accordance with their joint commitment to Equity, Diversity and Inclusion. We, individually and collectively, are committed to ensuring the following:

1. The RFHS community is a safe and welcoming place for all people.
2. All Learners, faculty, staff and other individuals in the RFHS community are respected.
3. The RFHS community is H5er because it recognizes, embraces and values its differences.
4. The faculty, staff and Learner populations are representative of the populations we serve in Manitoba.
5. We seek to understand the effects of colonization on Indigenous communities.
6. We treat each other with unconditional respect.
7. We are accountable to each other for our behaviour.
8. We are open, honest and authentic in our dealings with each other.
9. We will take action and speak up when we believe others are disrespected in our presence.
10. We will continually grow and learn together to be a H5 community of valued people.

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3. DEFINITIONS

3.1 “Diversity” includes all the ways in which people differ, and it encompasses all the different characteristics that make one individual or group different from another. It is all-inclusive and recognizes everyone and every group as part of the diversity that should be valued. A broad definition includes not only race, ethnicity, and gender - the groups that most often come to mind when the term “diversity” is used — but also age, national origin, religion, disability, sexual orientation, socioeconomic status, education, marital status, language, and physical appearance. It also involves different ideas, perspectives, and values.

3.2 “Equity” is the guarantee of fair treatment, access, opportunity, and advancement for all Learners, faculty, and staff, while at the same time striving to identify and eliminate barriers that have prevented the full participation of some groups. The principle of equity acknowledges that there are historically underserved and underrepresented populations and that fairness regarding these unbalanced conditions is needed to assist equality in the provision of effective opportunities to all groups.

3.3 “Historically Under-Represented Groups” means the four designated groups pursuant to the Employment Equity Act: women, Indigenous peoples, persons with disabilities, and members of racialized communities, as well as other historically under-represented groups such as 2STLGBQ+1, refugee and immigrant groups as well as others.

Note: “2STLGBQ+” is an acronym describing sexual and gender minority communities namely the two-spirit, transgender, lesbian, gay, bisexual, queer and questioning community. The “+” recognizes the diversity of identities and represents many more sexual orientations and gender identities not captured within the acronym.

3.4 “Inclusion” is the act of creating environments in which any individual or group can be and feel welcomed, respected, supported, and valued to fully participate. An inclusive and welcoming climate embraces differences and offers respect in words and actions for all people.

3.5 “Indigenous peoples” means First Nations, Metis and Inuit people.
“Learner” means an individual registered, enrolled, or classified as a student within or with the University of Manitoba, participating in any of the College programs or Rady Faculty of Health Sciences programs including the IHP Program.

3.6 “Learner” means an individual registered, enrolled, or classified as a student within or with the University of Manitoba, participating in any of the College programs or Rady Faculty of Health Sciences programs including the IHP Program.

3.7 “Principles of Reconciliation” are as documented by the Truth and Reconciliation Commission of Canada to guide its renewed relationships with First Nations, Metis, and Inuit people. As set out in the RFHS Reconciliation Action Plan, these principles include:

1. The United Nations Declaration on the Rights of Indigenous Peoples is the framework for reconciliation.
2. First Nations, Inuit and Metis peoples have Treaty, constitutional and human rights that must be respected.
3. Reconciliation is a process of healing of relationships that requires truth sharing, apology, and commemoration that acknowledge and redress past harms.
4. Reconciliation requires constructive action on addressing the ongoing legacies of colonialism that have destructive impacts on Indigenous peoples’ health.
5. Reconciliation must create a more equitable society and close the gaps in health.
6. All Canadians share the responsibility.
7. The perspectives and understandings of Traditional Knowledge Keepers are vital.
8. Reconciliation requires political will, joint leadership, trust building, accountability, transparency and a substantial investment of resources.

1 “2STLGBQ+” is an acronym describing sexual and gender minority communities namely the two-spirit, transgender, lesbian, gay, bisexual, queer and questioning community. The “+” recognizes the diversity of identities and represents many more sexual orientations and gender identities not captured within the acronym.

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4. POLICY STATEMENTS

Equity, Diversity and Inclusion Commitment

4.1 The RFHS and its Colleges commit to embedding Equity, Diversity and Inclusion throughout every area and level of the RFHS and the Colleges. In that respect, the RFHS Equity, Diversity & Inclusion Committee is established to act as the main discussion and advisory committee to the RFHS Dean & Vice-Provost (Health Sciences) in relation to issues of Equity, Diversity & Inclusion.

Faculty and Staff – Recruitment (Selection and Hiring)

4.2 The RFHS and its Colleges shall promote and implement inclusive recruitment and hiring practices, including implementing measures for the identification and removal of artificial barriers to the selection and hiring of Historically Under-Represented Groups, and to take steps to improve the employment status of these groups by increasing their participation in all levels of employment. At a minimum:

a) Best practices will be developed for promoting Equity, Diversity and Inclusion at each stage of planning for, recruiting, hiring and retaining diverse faculty and staff, and will actively implement employment equity;

b) Targeted outreach and selection methodologies will be used that avoid biases and barriers to address areas of under-representation of Historically Under-Represented Groups;

c) Training for all search and selection committees will be provided to ensure the recruitment and retention of diverse faculty and staff, avoiding unintended bias and building strategies to build diverse candidate pools.

Faculty and Staff Retention (Training, Development and Mentorship)

4.3 The RFHS and its Colleges commit to implementing Equity, Diversity and Inclusion efforts in its retention (including training, development and mentorship) of its faculty and staff. In particular, the RFHS and its Colleges shall, at a minimum:

a) Review the RFHS/College’s current orientation process for new staff and faculty to ensure it is effectively welcoming and connecting with new members;

b) Implement systemic ways to ensure women and other Historically Under-Represented Groups achieve leadership positions within the RFHS/College;

c) Review and enhance the career-planning and mentoring system(s) for faculty and staff.

Learners – Recruitment, Admissions and Retention

4.4 The RFHS and its Colleges commit to:

a) Recruitment and retention of Learners from Historically Under-Represented Groups, to ensure Learners are a reflection of the population the RFHS/Colleges serve. The RFHS/Colleges shall review and revise, as necessary, their admissions policies, procedures and requirements to reflect this commitment.

b) Ensure all Learners receive orientation to Equity, Diversity and Inclusion.

Learners - Curriculum

4.5 The RFHS and its Colleges commit to provide a diverse educational experience for all Learners through an inclusive curriculum that:

a) Is inclusive, respectful, safe and free from mistreatment;

b) Reflects the perspectives and experiences of a pluralistic society;

c) Reflects the perspective, world views and contributions of Indigenous communities;

d) Promotes understanding of health disparities and inequities;

e) Builds insight about Historically Under-Represented Groups and populations and the capacity to serve them competently;

f) Provides curricular learning experiences that include patient cases that represent diversity within the curriculum, as well as a variety of practice settings (such as First Nations communities; small, remote, northern and rural communities; complex health care facilities; community health agencies);

g) Fosters learner interaction in small group sessions;

h) Develops service-learning experiences with volunteer and community groups.

The RFHS/Colleges shall review and revise, as necessary, their curriculum to reflect this commitment.

Accessibility

4.6 The RFHS and its Colleges commit to cultivate positive dialogue about stereotypes regarding accessibility and accommodation, with a focus on improving the understanding of the needs, the process for accommodation, and how accommodations are beneficial. The RFHS/Colleges shall review their practices and processes to ensure compliance with applicable legislation and complementary policies.

Committees

4.7 The RFHS and its Colleges will strive to achieve diverse membership among their standing and ad hoc committees, working groups, consultants, advisory and community partners, to ensure differing perspectives and experiences with the goal of maintaining objectivity and a balanced skill-set for matters under review and consideration.

Skill-Building Workshops

4.8 The RFHS and its Colleges will initiate skill-building workshops for Learners, faculty and staff aimed at addressing Equity, Diversity and Inclusion goals and challenges.

Research

4.9 The RFHS and its Colleges encourage research that responds to the needs of the population the RFHS and its Colleges serve, and encourages compliance with the Equity, Diversity and Inclusion Action Plan of the Canada Research Chairs as well as other EDI plans that may be applicable.

Outreach

4.10 The RFHS and its Colleges will actively seek out and build partnerships, including supporting outreach programs and initiatives with communities, schools, diverse community organizations and individuals, including Indigenous peoples, in order to create, maintain and enhance career pathing programs and social accountability initiatives, coordinated through the RFHS Office of Community Engagement and other units of the RFHS and member colleges (e.g., Ongomiizwin).

Communications

4.11 RFHS External Relations shall ensure the commitment to Equity, Diversity and Inclusion be considered and featured in print ads, website materials and other materials used for Learners, faculty, staff and public promotion.

All Faculty, Staff and Learners

4.12 All Learners, faculty, and staff of the RFHS and its Colleges are responsible to:

• Educate themselves on matters relating to Equity, Diversity and Inclusion;
• Create and maintain a respectful working and learning environment that respects and values the rights and dignities of all individuals;
• Report any activity that is contrary to the Prevention of Learner Mistreatment Policy or the University of Manitoba Respectful Work and Learning Environment Policy, including use of the “Speak Up” button.

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5. PROCEDURE STATEMENTS

Implementation Plan

5.1 The above policy statements are minimum principle-based requirements. Working through the RFHS Director, Equity, Diversity and Inclusion, implementation/action plans will be developed for each policy statement, which may include the establishment of working groups to develop specific action items.

RFHS and College Leads

5.2 At the request of the RFHS Director, Equity, Diversity and Inclusion, each College and RFHS Program (not otherwise associated with a College) shall identify one or more lead(s) respecting the Colleges’/Programs’ efforts in implementing particular policy statements relating to the Equity, Diversity and Inclusion.

Targets

5.3 As part of the implementation/action plans, the RFHS/Colleges, with the RFHS Director, Equity, Diversity and Inclusion shall set specific targets and outcome measures to meet the commitments made in this policy, keeping in mind the RFHS goal to have Learners, faculty, and staff be reflective of the population served by the RFHS and its Colleges, and to achieve greater representation of Historically Under-Represented Groups.

Tracking

5.4 In order to determine whether the RFHS and its Colleges are meeting the set targets and outcome measures, the RFHS/Colleges shall, at minimum, track its Learners, faculty, and staff from Historically Under-Represented Groups through surveys and/or other mechanisms, and adopt mechanisms to address gaps.

Reporting

5.5 The RFHS Director, Equity, Diversity and Inclusion shall coordinate the reporting on the implementation and outcomes in Equity, Diversity and Inclusion. A formal written report shall be provided to the RFHS Equity, Diversity and Inclusion Committee at least once per year. Each College/RFHS Program shall provide the necessary information respecting the College’s implementation of Equity, Diversity and Inclusion, including efforts, outcomes and tracking data, to the RFHS Director, Equity, Diversity and Inclusion.

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6. REFERENCES

6.1 Diversity, Inclusion and Equity Guidelines, November 2016, Dalhousie University, Faculty of Medicine

6.2 Equity, Diversity and Inclusion Action Plan, Canada Research Chairs

6.3 Equity, Diversity and Inclusion: Best Practices for Recruitment, Hiring and Retention, Canada Research Chairs

6.4 The Rady Faculty of Health Sciences Reconciliation Action Plan

6.5 The Rady Faculty of Health Sciences Strategic Framework

6.6 Red River College Equity, Diversity and Inclusion Policy

6.7 The Accessibility for Manitobans Act (Manitoba)

6.8 The Employment Equity Act (Canada)

6.9 The Human Rights Code (Manitoba)

6.10 Framework for Research Engagement with First Nation, Metis, and Inuit Peoples

6.11 The Prevention of Learner Mistreatment Policy (Max Rady College of Medicine) (under review)

6.12 University of Manitoba Respectful Work and Learning Environment Policy

6.13 University of Manitoba Accessibility Policy and Procedures

6.14 The University of Manitoba Strategic Plan

6.15 Disruption of all Forms of Racism Policy

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7. POLICY CONTACT

Please contact the RFHS Director, Equity, Inclusion and Diversity with questions regarding this policy.

Policy name	Interactions with health-related industries
Application and scope	Staff, faculty members and learners of the Rady Faculty of Health Sciences and its colleges and programs
Approved date	November 9, 2022
Review date	Five (5) years from approval date
Revised date
Approved by	Dean’s Council, Rady Faculty of Health Sciences – November 9, 2022

1. BACKGROUND and SCOPE

1.1 Members of the Rady Faculty of Health Sciences (“RFHS”) and its Colleges and Programs interact with representatives of Industry. Interactions with Industry occur in a variety of contexts, including marketing of new pharmaceutical or dental products, devices and/or equipment; on‐site training for newly purchased devices; educational support of Learners and practitioners; and in the support of research activities including clinical trials and scholarly publication.

1.2 Interactions with Industry are important and can be beneficial to the University of Manitoba (“University”). For example, they help ensure timely and broad access to healthcare advances and new technologies and to clinical trials that are industry‐initiated. Collaboration with Industry is also essential to the development of new diagnostic and therapeutic products, devices, and technology.

1.3 However, these interactions must avoid any actual, potential, or perceived conflicts of interest that may affect the integrity of the RFHS’s education, training and research programs, or the reputation of either the RFHS Member or the RFHS itself. This policy is not intended to inhibit such interactions, but to ensure transparency in these relationships, the absence of undue influence, and to ensure that real or potential conflicts of interest are managed in the best interests of the RFHS and its members.

1.4 This policy provides a set of requirements that RFHS faculty, staff, students, and trainees will use to ensure that their interactions result in optimal benefit to clinical care, education, and research, and that maintain the public trust.

1.5 This policy is meant to be consistent and compliant with the University of Manitoba policies, such as the Conflict of Interest Policy and the Gifts and Gratuities Offered to University Employees Policy. Where any portion of this policy conflicts with these University policies, the latter will govern. Where this policy is silent on a matter, University policies shall govern the matter.

1.6 More detailed or prescriptive College or Program‐specific policies or guidelines may exist, and shall, at minimum, meet the requirements of this policy. Please reference any applicable College or Program‐specific policies or guidelines.

1.7 This Policy is meant to apply to those RFHS interactions with Industry as detailed herein. The timing and/or location of the RFHS interaction are not means by which to exclude this Policy’s application.

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2. DEFINITIONS

The terms in this Definitions section are defined for the purposes of this policy, and are in addition to definitions set forth elsewhere in this policy:

2.1 “Continuing Professional Development (CPD) programs” are those educational events, activities and conferences designed primarily to address the learning needs of practicing health providers.

2.2 “Industry” means the fields of, and representatives in, pharmaceuticals, biotechnology, health‐related devices, health information technology, hospital and research equipment, and health care supply and services including dental labs and dental management companies. For the purposes of this document, it does not include not‐for‐profit health entities or entities in sectors such as financial or insurance institutions.

2.3 “Interactions with Industry” means the following types of interactions with Industry, as more particularly described in this policy:

• Gifts including food and drink
• Individual attendance at social events sponsored or hosted by Industry
• Individual attendance at CPD programs receiving financial support from Industry
• Industry support for the RFHS, Colleges and Programs;
• Individuals engaging with Industry as Speakers, Moderators or Consultants
• Ghostwriting;
• Meetings with Industry/site access for any of the above purposes.

2.4 “Learner” means an individual registered at the University within a program of the RFHS or one of its Colleges, on a full time or part time basis or as a special student. A Learner can be at the undergraduate, graduate or postdoctoral level, and includes non‐professional graduate students, residents, and fellows and individuals registered at another institution but attending the RFHS on a temporary basis as part of an elective or similar program.

2.5 “RFHS Members” mean all Learners, employees, faculty member/academic staff (individuals with an academic appointment in the RFHS or its Colleges/Departments), as well as any other individuals involved in activity under the auspices of the RFHS (such as volunteers, external parties, contractors and suppliers).

2.6 “Gift” is an item, hospitality, or other benefit given to an individual without the expectation of payment, which would not have been offered if not for a person’s relationship or position at the university or work within the scope of a person’s UM employment. Receipt of a gift may impact or be perceived to impact the ability of the receiver to make decisions with impartiality, integrity and in the best interests of the university.

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3. POLICY AND PROCEDURE STATEMENTS

3.1 Gifts to Individuals ‐ A RFHS Member shall not accept a Gift from Industry representatives. Gifts include food or drink. Gifts also include, but are not limited to, textbooks, electronic media, gift certificates, tickets to sports or cultural events, devices, products or services, travel, hotel accommodations, entertainment, research equipment or funding, and payments for attending a meeting. Promotional items without significant value that are distributed routinely, such as pens or note pads, are excluded from this definition of Gifts.

3.2 Individual Attendance at Social Events ‐ A RFHS Member may not accept free admission to receptions, dinners, sporting, or cultural events from Industry. This applies both to stand‐ alone hospitality events and to those associated with a conference or educational program. Attendance is permitted at dinners and social events associated with a conference or other education event when admission is restricted to persons purchasing tickets or paying registration fees for the conference or event.

Social events at educational programs supported by Industry must not compete with nor take precedence over the educational elements. In general, such arrangements should be in keeping with those that would normally be made without such sponsorship.

3.3 Individual Attendance at CPD Programs ‐ RFHS Members are permitted to participate in accredited or unaccredited CPD programs that receive financial support from Industry. Such programs may be held on‐ or off‐campus but must not be held in a restaurant or lounge, including those located in private clubs. Accredited CPD events require a registration fee be charged to registrants to avoid a perceived or real influence on educational content and to cover hospitality costs. RFHS Members may participate in learning activities, programs and conferences that are unaccredited, but must pay the full cost of any food and drink provided. Organizers are expected to offer registration systems that facilitate such payment by attendees

3.4 Meeting with Industry/Site Access ‐ Industry representatives are welcome to meet with RFHS Members in all non‐patient care areas and should be on an appointment basis. All Interactions between Learners and Industry representatives must be mentored and monitored by a faculty member.

There are circumstances in which it is helpful to have Industry representatives present in a clinical care or educational setting, such as an operating suite and a simulation facility, respectively. This access will be governed by relevant site policies and procedures and should ensure that such interaction is focused on education and training for staff and trainees.

3.5 Industry Support for the RFHS, Colleges, Programs ‐ The RFHS, Colleges and Programs benefit from financial and in‐kind support provided by Industry in a variety of forms. Unless with the University that stipulates the intended use of the support, and which is transparent to both parties and, when required, to the public. As well, the University of Manitoba Purchasing Policy and Procedure must be followed. Please contact the Office of Legal Counsel to determine the type of agreement/receive the standard agreement and review the process required. These funds or donated products must be provided to the RFHS, College, to an individual Department, or to an account held by a Regional Health Authority or Shared Health (if permitted pursuant to existing affiliation agreements), and not be held by an individual RFHS Member. Departments or Units must ensure that these monies are held separately from other funds.

3.6 The following additional provisions apply to the following types of support:

3.6.1 Hospitality ‐ Financial and in‐kind support provided by Industry specifically designated for hospitality shall not be accepted.

3.6.2 Research ‐ All RFHS Members who participate in the design, conduct, analysis, or reporting of Industry‐funded research shall ensure that a signed multi‐partner agreement is in place which is satisfactory to the researcher, the head of the College/Department in which the researcher holds his/her primary appointment, the Industry partner, and the institution(s) where the research will be conducted. All research projects must be approved by the Research Ethics Board of the University of Manitoba and comply with university policies that pertain to research such as the Research Agreements Policy and the Institutional Costs of Research Policy: Recover and Distribution, including any approvals as required by the Research Ethics Board of the University of Manitoba. Please contact the Office of Legal Counsel for questions around the required agreement and process required.

Research receiving such financial support must be carried out independently and objectively for the purposes of the advancement of scientific knowledge or clinical efficacy. RFHS Members shall not enter into agreements that limit their right to publish or disclose results of the study or report adverse events that occur during the course of the study.

3.6.3 Education: Undergraduate, Graduate and Postgraduate Programs and Retreats ‐ Support may be accepted from Industry or related entities for Learner academic days, retreats, meetings, career fairs or similar events. However, such support can only be used for educational aspects of the event (speaker fees, printing, learning materials, audiovisual costs etc.) and not for food, drink, lodging, social events, or other hospitality aspects. Student Interactions with Industry representatives must be mentored and monitored by a faculty member. Notwithstanding the foregoing, modest food and drink provision (e.g. muffins, sandwiches or pizza) may be provided with the Industry support should a sponsored session be taking place during commonly accepted meal times.

Support by Industry that is provided for Learner educational programs in the form of funding or a donated product must be free of any actual or perceived conflict of interest. It must be governed by a written agreement that stipulates the intended use of the support. This also applies to support received from educational companies or other entities that act as intermediaries for Industry. Such written agreements must receive prior approval by the Department Head or appropriate Associate Dean, prior to being signed by the Dean. Changes may be required to the terms of such agreements to bring them into compliance with University and/or RFHS policies.

3.6.4 Scholarships/Other Educational Funds for Learners ‐ Industry support for Learners’ participation in education programs and conferences must be free of any actual, potential, or perceived conflict of interest. All financial support for Learners must be specifically for the purposes of education and must comply with the following requirements:

• The Department, Program or Unit must select the Learners for participation;
• The funds must be provided to the Department, Program or Unit and not directly to the Learner and be governed by a written agreement;
• The Department, Program, or Unit determines that the education conference or program has educational merit; and
• There is no implicit or explicit expectation that the participant must provide something in return for participation in the educational program.

3.6.5 CPD Programs ‐ Industry support for CPD programs must be free of any actual or perceived conflict of interest and must be provided to the RFHS, one of its Colleges, education programs, or to an individual Department, and not to an individual RFHS Member. Grants to fund CPD programs must be governed by written agreements that stipulate the intended use of the support and that are completed prior to the event occurring. Such agreements should be in a format acceptable to the University. Funds that are provided by educational groups or other entities that act as intermediaries for Industry such as health education companies must be managed in the same way. Financial support specifically designated for hospitality is not permitted.

The Office of Continuing Competency and Assessment has defined policies and processes respecting commercial support for accredited and unaccredited CPD programs/events, as well as commercial exhibits and can be referenced at: http://umanitoba.ca/faculties/health_sciences/cca/forms.html.

3.6.6 Regularly Scheduled Series (i.e. Study Clubs, Journal Clubs) ‐ Food and drink provided at regularly scheduled series (Grand and Section Rounds, Quality Assurance Rounds, Study Clubs, Journal Clubs, etc.) must not be purchased with funds provided directly or indirectly by Industry. These events are viewed as part of the academic mission of the University and commonly are key learning events for Learners.

3.6.7 Visiting Professors ‐ Visiting Professor events are organized under the auspices of a Department, Section or Program in the College. The control of content, planning and budget rests with that Unit. Funds may be received from Industry in support of Visiting Professor events that are governed by a written agreement. As part of the hospitality extended to visiting professors, a social event in honour of the visitor may be paid for from such funds for three University faculty members and the visiting professor, similar to the guideline for faculty recruitment visits.

3.6.8 Procurement Contracts ‐ A RFHS Member may accept food, drink, and travel related expenses provided in the context of contracts with Industry for healthcare devices, equipment, and other technologies. Such benefits must be stipulated in the contract and be provided in the context of educational and programs designed to ensure that RFHS Members acquire the skills and knowledge necessary to use such devices or equipment safely and effectively.

3.7 RFHS Members engaging with Industry as Speakers, Moderators or Consultants ‐ When an RFHS Member is engaged by Industry for consulting or speaking services, including service on advisory boards, a contract must be provided that includes specific tasks and deliverables and identifies payments commensurate with the tasks assigned. These agreements must link deliverables and payments to specific scheduled or planned events or projects to be completed within a specified term.

3.7.1 ‐ Contracts between RFHS Members and Industry must be reviewed in a timely fashion by the Department Head or College Dean, as applicable and for matters affecting a Department Head, by the College Dean. The agreement is required to be with Industry and the RFHS Member individually, as the individual is engaging with Industry outside of their relationship with the University of Manitoba (i.e. the University of Manitoba is not a party to this agreement). The Department Head/College Dean may require RFHS Members to request changes to the terms of such contracts to bring them into compliance with University and/or RFHS/College policies before approving them.

3.7.2 ‐ The Department Head/College Dean may decline approval of a RFHS Member’s request for Industry engagement if the proposed conditions including duties and time commitments are deemed likely to interfere with the RFHS Member’s duties and responsibilities to the Department, College and/or RFHS. When RFHS Members are engaged in the commercialization of new technologies through partnership or ownership, more latitude may be allowed to facilitate the RFHS Member’s role in ensuring the success of the venture. In cases where the Department Head/College Dean has declined approval, and the RFHS Member disagrees with the result, the RFHS Member may submit an appeal in accordance with the University’s Conflict of Interest Policy.

3.7.3 ‐ While receiving compensation is acceptable for providing substantial professional services, a RFHS Member may not accept compensation unless the individual has played a substantial role. In particular, RFHS Members engaged by Industry as speakers or moderators of scientific sessions must comply with the following conditions:

• They must have recognized expertise in the topic area.
• They must prepare the content of their talks themselves.
• They must provide a fair and balanced discussion of the current evidence and treatment options.
• They or the sponsor must disclose the fact of financial support to the participants

3.7.4 ‐ RFHS Members engaged by Industry as consultants, including membership on advisory boards, must have recognized expertise related to the services being purchased. These services may include scientific, medical, technical or methodological advice or the preparation of educational programs. They must comply with the following conditions:

• Purchased services cannot include deliberations or activities directly related to the marketing of products.
• RFHS Members asked by government, Shared Health, regional health authorities, hospitals or a College to provide advice or to participate in deliberations relevant to the selection, evaluation and or purchase of drugs or devices must disclose all Industry compensation within the previous two years, or other time period stipulated by the purchasing organization.
• Compensation must be consistent with applicable College or Program‐specific policy or guideline. Please reference any applicable College or Program‐specific policies or guidelines

3.7.5 ‐ Individuals shall not accept compensation in exchange for listening to a promotional talk, for attending a continuing education event, or for any other activity in which the attendee has no other role except that of a participant.

3.8 Ghostwriting ‐ All RFHS Members are prohibited from publishing or producing articles, presentations, or other forms of media solely under their own name that are written in whole or in part by Industry representatives.

3.9 RFHS Members – Disclosure of Relationships with Industry ‐ Consistent with the University of Manitoba Conflict of Interest Policy and its Procedure, and with any pertinent collective agreements, RFHS Members will formally disclose financial and other relationships with Industry in a confidential manner to their Department Head, Director or Supervisor. This disclosure must occur at the time of their first appointment or hiring and thereafter as soon as they become aware of the existence of an emerging actual, potential, or perceived conflict of interest. A confidential disclosure form may be used.

3.9.1 ‐ As noted above, written agreements are required when RFHS Members are engaged by Industry for consulting, speaking or research services, and the Department Head/College Dean is required to approve all such agreements. This affords the Department Head/College Dean the ongoing opportunity to be aware of such relationships and ensures the interests of the RFHS/College and the member are safeguarded.

3.9.2 ‐ The presence of relationships with Industry must be disclosed in a general manner to undergraduate, graduate, postgraduate and CPD learners by faculty or staff prior to any educational activity such as lectures, seminars or workshops. This includes all relationships over the previous two years, such as:

• Any direct financial payments including honoraria;
• Membership on advisory boards or speakers bureaus;
• Industry‐funded grants or clinical trials;
• Patents on a drug, product or service;
• All other investments or relationships that could be seen by a reasonable participant as having the potential to influence the content of the educational activity.

3.9.3 ‐ Information provided in this manner includes the name of the commercial interest and the nature of the relationship the person has with each commercial interest. Information that an individual has no relevant financial relationship must also be disclosed in advance to the learners. Faculty or staff with supervisory responsibilities for learners, trainees, or staff should ensure that any conflict of interest they might hold does not affect or appear to affect his or her supervisory role.

3.10 Reporting and Non‐Compliance with this Policy ‐ Should a concern arise respecting suspected contraventions of this policy, Learners can report concerns to any of their teachers, preceptors, course/rotation directors, administrative staff members, Department Heads, Services at Bannatyne Campus representatives, including Student Advocacy, according to personal comfort and preference. Faculty members and staff may contact their supervisor, director, Department Head, College Dean or RFHS Dean.

Remedial measures resulting from a breach of this policy will depend on the circumstances, on the seriousness of the behaviour, on any mitigating factors and on applicable University policy, bylaw, collective agreement, or academic regulation. The following list provides examples of remedial measures and is not meant to be exhaustive nor necessarily represents a progression of measures:

• Counselling of the individual involved;
• Attendance at educational session(s) on conflict of interest;
• Requiring the individual to return any monies received for the
• improper relationship with Industry, in contravention of these Policy;
• Prohibited or restricted access to the learning environment and/or to Learners;
• Academic consequences such as remediation, probation, notation on the performance record, dismissal/expulsion from the College/Program;
• Termination of employment or academic appointment.

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4. REVIEW AND EFFECT ON PREVIOUS STATEMENTS

4.1 The Review Date for this Policy and Procedure is five (5) years from the date it is approved by the approving body. In the interim, this document may be revised or repealed if:

(a) The Dean, Rady Faculty of Health Sciences & Vice‐Provost (Health Sciences), with appropriate approvals, deems it necessary or desirable to do so;

(b) It is no longer legislatively or statutorily compliant; and/or

(c) It comes into conflict with another governing document of the RFHS or the University of Manitoba.

4.2 If this document is revised or repealed, any related Rady Faculty of Health Sciences documents shall be reviewed as soon as possible to ensure that they comply with the revised document, or are in term revised or repealed.

4.3 This Policy supersedes all previous governing documents dealing with the subject matter addressed in this document.

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5. REFERENCES

5.1 Interactions between the Max Rady College of Medicine and Health‐Related Industries Policy

5.2 Conflict of Interest Policy, University of Manitoba

5.3 Gifts and Gratuities Offered to University Employees Policy, University of Manitoba and Pharmaceutical, Biotech, Medical Device, Medical/Dental Supply, and Research Equipment Supplies Industry, Western University

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6. PUBLICATIONS

6.1 DeJong C, Aguilar T, Tseng CW, Lin GA, Boscardin WJ, Dudley RA. Pharmaceutical Industry‐ Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries. JAMA Internal Medicine. 2016;176(8):1114‐10

6.2 Austad KE, Avorn J, Kesselheim AS. Medical students’ exposure to and attitudes about the pharmaceutical industry: a systematic review. PLoS Med. 2011;8(5):e1001037

6.3 Brennan TA, Rothman DJ, Blank L, Blumenthal D, Chimonas SC, Cohen JJ, et al. Health Industry Practices That Create Conflicts of Interest: a Policy Proposal for Academic Medical Centers. JAMA. 2006;295(4):429‐33

6.4 Jason Dana and George Loewenstein, "A Social Science Perspective on Gifts to Physicians From Industry," Journal of the American Medical Association 290 (July 9, 2003): 252‐255

6.5 T.S. Caudill et al., "Physicians, Pharmaceutical Sales Representatives, and the Cost of Prescribing," Archives of Family Medicine 5 (April 1996): 201‐206

6.6 Jerry Avorn et al., "Scientific Versus Commercial Sources of Influence on the Prescribing Behavior of Physicians," American Journal of Medicine 73 (July 1982): 4‐8

6.7 Lurie et al., "Pharmaceutical Representatives in Academic Medical Centers: Interaction with Faculty and Housestaff," Journal of General Internal Medicine 5 (May‐June 1990): 240‐243

6.8 James Orlowski and Leon Wateska, "The Effects of Pharmaceutical Firm Enticements on Physician Prescribing Patterns," Chest 102 (July 1992): 270‐273

6.9 Joel Lexchin, "Interactions Between Physicians and the Pharmaceutical Industry: What Does the Literature Say?" Canadian Medical Association Journal 149 (Nov. 15, 1993): 1401‐1406

6.10 Ashley Wazana, "Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?" Journal of the American Medical Association 283 (Jan. 19, 2000): 373‐380. Brennan et al., 429‐433

6.11 Holden ACL, Spallek H, “Looking Gift‐horses in the Mouth: Gift‐giving, Incentives and Conflict of Interest in the Dental Profession” Journal of Law & Medicine. 25(3):794‐799, 2018 Apr.

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7.0 POLICY CONTACT

Please contact the Dean, RFHS & Vice‐Provost (Health Sciences) with questions regarding this document.

Guideline name	Learner immune status requirements
Application and scope	Learners of the Rady Faculty of Health Sciences and its Colleges and Programs
Approved date	January 11, 2023
Review date	Five (5) years from approval date
Revised date
Approved by	Applicable Department Councils - July 27, 2022 College Councils; Pharmacy, Dentistry, Medicine, Rehabilitation Sciences, Nursing - August 4, 2022 Dean’s Council, Rady Faculty of Health Sciences - August 15, 2023 Faculty Executive Council, Rady Faculty of Health Sciences - August 23, 2022 Faculty Grad Studies Programs and Guidelines Committee - September 20, 2022 Faculty Grad Studies Executive Council - October 14, 2022 Faculty Graduate Studies Council - November 4, 2022 Senate Committee on Instruction and Evaluation - November 17, 2022 Senate Executive - December 14, 2022 Senate - January 11, 2023

 

 

 

 

 

 

 

 

 

1. BACKGROUND AND SCOPE

1.1 The Rady Faculty of Health Sciences is committed to ensuring patient safety as well as a safe work and learning environment for its learners, staff, and faculty. The Learner Immune Status Requirements policy has been developed to protect the wellbeing of our community and is derived from the recommendations found in the Canadian Immunizations Guide, the
Canadian Tuberculosis Standards, Public Health Agency of Canada, National Advisory Committee on Immunization, as well as in consultation with experts in the relevant fields.

1.2 The purpose of this policy is to outline the immunization expectations and requirements of learners in the Rady Faculty of Health Sciences.

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2. DEFINITIONS

2.1 Immune Status Requirements – Documented and up-to-date tests and immunizations that are necessary in order to ensure immunity to, or absence of infection from a range of diseases. The current Immune Status Requirements, which may be changed from time to time, include immunizations and/or tests for tetanus, diphtheria, pertussis, polio, measles, mumps, rubella, varicella, Hepatitis B, and influenza, COVID-19, as well as testing for tuberculosis infection.

2.2 Rady Faculty of Health Sciences Immunization Program (“Immunization Program”) – The Immunization Program provides immunization services to all registered learners of Rady Faculty of Health Sciences pre-licensure health professional programs.

2.3 Student Manual – A document updated annually which describes the Immune Status Requirements for learners enrolled in the Rady Faculty of Health Sciences’ programs. The document also provides information on vaccines, vaccine preventable diseases, privacy legislation, costs of services, and additional health information relevant to learners.

2.4 Immunization Package – A document package consisting of a consent form, personal information and health questionnaires which all learners of Rady Faculty of Health Sciences must complete to ensure continued enrolment in their program of study.

2.5 Learners – Individuals who are registered in pre-licensure health professional programs of the Rady Faculty of Health Sciences that includes:

Dentistry, Dental Hygiene, Genetic Counselling, Medicine, Midwifery, Nurse Practitioner, Nursing, Occupational Therapy, Pathology Assistant, Pharmacy, Physical Therapy, Physician Assistant Studies, and Respiratory Therapy students. Not included are non-health professional program graduate students where there are no clinical rotations or exposures.

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3. POLICY AND PROCEDURE STATEMENTS

3.1 All learners must comply with the immunization and testing requirements of the Rady Faculty of Health Sciences, listed in the Student Manual. The Student Manual is required reading for all new learners.

3.2 Learners may request an exemption from the requirements of this policy as an academic accommodation based on The Manitoba Human Rights Code. Requests for exemptions should be directed to the Immunization Program which will approve clinically indicated reasons for exemption that have been determined in consultation with Student Accessibility Services. Other exemptions will be considered on a case-by-case basis consistent with the Rady Faculty of Health Science’s legal obligations, in consideration of applicable essential skill requirements, and in accordance with the Student Accessibility Policy and Student Accessibility Appeal Procedure. If an exemption is approved, different immunization or testing requirements may be indicated for such learners.

3.3 The Immunization Program shall provide an information session regarding Immune Status Requirements for newly registered learners in the Rady Faculty of Health Sciences. This information session is to complement the mandatory Immunization Program Orientation available on UM Learn and shall be scheduled as early as practicable following registration, but must occur before the learner attends any clinical placements.

3.4 The Immune Status Requirements may change from time-to-time. The Immunization Program shall discuss and seek approval from the Faculty. The Immunization Program shall notify learners of the changes in requirements. It is the responsibility of the learners to comply with revised and applicable requirements as soon as practicable following notification.

3.5 Learners who do not comply with the Immune Status Requirements will be subject to disciplinary considerations based on applicable policies and procedures. This may include restriction from participation in and/or completion of components of the academic program including clinical placements or rotations. A learner’s continued non-compliance and subsequent inability to meet the requirements of their program, may result in the learner being required to withdraw from the program in which they are registered.

3.6 The Immunization Program can assist learners in meeting the requirements and assist with required documentation of a specific external teaching site if these are different from the requirements of the Rady Faculty of Health Sciences.

3.7 Learner health records are protected by The Personal Health Information Act (PHIA) of Manitoba. Only the minimal amount of health information required will be collected, used, or disclosed. Personal health information will be used and disclosed in accordance with The Personal Health Information Act (PHIA).

3.8 The Immunization Program will comply with The Workplace Safety and Health Act of Manitoba as amended from time to time.

3.9 The immune status record for every learner will be kept for 10 years after the learner’s expected date of graduation, in accordance with the University’s authorized records retention schedules. The Immunization Program will destroy all immune status records in a secure and confidential manner, consistent with accepted methods of disposal of health records. Learners may request a copy of their record at any time while the program has these records. All learners shall receive a copy on request of their immune status record upon graduation.

RESPONSIBILITIES OF LEARNERS

4.1 All learners must comply with the immunization and testing requirements of the Rady Faculty of Health Sciences and the Immunization Program. Learners seeking an exemption from the requirements of this policy must notify the Immunization Program and Student Accessibility Services and must provide all information required to assess the exemption request. Exemptions may not be possible based on a program’s essential skill requirements.

4.2 Learners must attend the immune status orientation session at the beginning of their first year of studies.

4.3 Learners must notify the Immunization Program if they wish to receive clinical services relating to the Immune Status Requirements from their own healthcare provider or from the Immunization Program.

4.4 Learners who have decided to obtain services from their own healthcare provider will do so at their own expense and must submit documentation of the relevant immunizations and tests by the deadlines provided. Learners who have decided to obtain services from the Immunization Program must attend school clinics or attend for blood testing diligently.

RESPONSIBILITIES OF THE IMMUNIZATION PROGRAM

4.5 The Immunization Program will review and maintain all health documentation in accordance with applicable policies, procedures and standards and follow up on outstanding documentation.

4.6 The Immunization Program will provide immune status orientation sessions for new learners.

4.7 The Immunization Program will provide training sessions for learner immunizers and will supervise immunization and tuberculin skin test clinics for learner clients.

4.8 The Immunization Program is a source of information to learners regarding immunizations and is the first point of contact for learners requesting information or assistance with immunization requirements.

4.9 The Immunization Program will provide immunization records to provincial immunization registry and to learners at graduation as well as upon request.

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5. REVIEW AND EFFECT ON PREVIOUS STATEMENTS

5.1 The Review Date for this Policy and Procedure is five (5) years from the date it is approved by the approving body. In the interim, this document may be revised or repealed if:

(a) The Dean, Rady Faculty of Health Sciences & Vice-Provost (Health Sciences), with appropriate approvals, deems it necessary or desirable to do so;

(b) It is no longer legislatively or statutorily compliant; and/or

(c) It comes into conflict with another governing document of the RFHS or the
University of Manitoba.

5.2 If this document is revised or repealed, any related Rady Faculty of Health Sciences documents shall be reviewed as soon as possible to ensure that they comply with the revised document, or are in term revised or repealed.

5.3 This Policy supersedes all previous governing documents dealing with the subject matter addressed in this document.

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6. REFERENCES

6.1 Canadian Immunizations Guide

6.2 Canadian Tuberculosis Standards

6.3 Public Health Agency of Canada 

6.4 National Advisory Committee on Immunization (NACI)

6.5 Manitoba Human Rights Code

6.6 Workplace Safety and Health Act of Manitoba

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7. POLICY CONTACT

Please contact the immunization program director with questions regarding this policy.

1. BACKGROUND

Members of the Rady Faculty of Health Sciences community are considered leaders and hold positions of trust; therefore, they are held to a higher standard of behavior.  These expectations extend to all areas of our public and private lives and steps must be taken to ensure professionalism is maintained.  

These guidelines are intended to provide general principles to be considered for learner led events for any participating staff, faculty members, and learners within the RFHS and its colleges, to ensure an acceptable level of professionalism, a safe learning and work environment, and respect for equity, diversity, and inclusion are maintained.

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2. PURPOSE

2.1 To provide guidance to learners, faculty members and staff of the Rady Faculty of Health Sciences (“RFHS”), University of Manitoba (“UM”), respecting participating in non-RFHS sanctioned, learner led events; and
        
2.2 While the potential to offend some will always exist, these guidelines have been created to provide guidance in understanding roles and responsibilities as members of the RFHS community, and to help inform what is appropriate behaviour at learner led events.

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3. DEFINITIONS

3.1 Learner led Event: a non-sanctioned event organized by learners that may take place on UM campuses or facilities and may include such events as Beer & Skits. 
        
3.2 Non-sanctioned event:  an event, gathering or activity that is neither organized nor endorsed by the RFHS, but may include participation by RFHS community members such as learner, faculty, staff, as well as members of the public. 

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4. GUIDELINES

Personal Conduct

4.1 Academic freedom and freedom of expression are fundamental values supported by the University of Manitoba and the RFHS.   

4.2 Learner led events give students a chance to connect with peers, have fun, and explore the idiosyncrasies of pursuing a career as a health professional.   While the participation in learner led events is an individual decision, caution should be exercised when considering and participating in a learner led event; behavior is expected to comply with professional standards, University policy, and legislation.

4.3 It is important to be aware that, even with non-sanctioned events, the person’s RFHS affiliation may still be identified, known, or presumed.  A “University Matter” is broadly defined, as provided in the Disclosures and Complaints Procedure.

4.4 In Manitoba, the Human Rights Code prohibits discrimination and harassment of any individual or group based on any of the personal characteristics as set out in the Human Rights Code (Manitoba). The Criminal Code of Canada contains provisions respecting hate speech.  Any interactions shall be free of harassment, discrimination, as well as public incitement, and wilful promotion, of hatred. 

Professional Standards

4.5 Professional Standards:  Each profession has its own governing body that may have statements or guidelines relevant to personal conduct that provide responsibilities for its members.  The following list is provided for reference and may not be exhaustive:

• Code of Ethics for Registered Nurses
• Code of Ethics and Standards of Psychiatric Nursing Practice
• College of Dental Hygienists of Manitoba utilize the Canadian Dental Hygienists Association Code of Ethics
• College of Occupational Therapists of Manitoba: Code of Ethics
• College of Pharmacists of Manitoba: Code of Ethics
• College of Physicians and Surgeons of Manitoba – adoption of Canadian Medical Association Code of Ethics and Professionalism
• College of Physicians and Surgeons of Manitoba:  Standards of Practice of Medicine
• College of Physiotherapists of Manitoba: Use of Social Media
• College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba: Social Media and Social Networking
• Manitoba Association of Registered Respiratory Therapists: Code of Ethics
• Manitoba Association of Registered Respiratory Therapists: Standards of Practice
• Manitoba Dental Association: Code of Ethics
• Practice Expectations for RNs
• University of Manitoba Policies and Values

4.6 Several University of Manitoba policies and values are relevant and applicable to personal conduct.  They include:

Access and Privacy Policy and Procedures

University members are required to comply with PHIA, FIPPA, and this policy to ensure the University meets its obligations under access and privacy legislation.

Use of Computer Facilities Policy and Procedures:  University members, including learners, agree to abide by this policy when they claim a user ID.  The policy outlines clear user responsibilities.

Respectful Work and Learning Environment Policy and Procedure: This policy, in part provides: “Members of the University Community, including every student and employee, are entitled to a respectful work and learning environment that is: (a) Free from Discrimination and provides for Reasonable Accommodation; (b) Free from Harassment; and (c) Collegial and conducive to early resolution of conflict between members of the University Community.”  It provides a process for complaint and resolution should there be a concern respecting a respectful work or learning environment.

Prevention of Learner Mistreatment Policy, Max Rady College of Medicine and the Prevention of Learner Mistreatment Guidelines, RFHS: Provides a commitment “to assuring safe, respectful and supportive working and learning environments in which all of its members are enabled and encouraged to excel.  This is an environment free of discrimination, harassment and mistreatment and one in which feedback regarding performance can be shared openly without concern for ridicule or reprisal.”  

It provides a process for complaint and resolution should there be a concern respecting learner mistreatment.

Discipline avenues for unprofessional conduct.

For learners, unprofessional conduct can result in discipline pursuant to the Student Discipline Bylaw; a program’s Professional Unsuitability Bylaw or a program’s essential/requisite skills and abilities document.  

For faculty members or staff, unprofessional conduct can result in discipline pursuant to an applicable collective agreement, human resources policy or employment standards law.

The University’s commitment to six fundamental values: honesty, trust, fairness, respect, responsibility and courage, defining Academic Integrity, should be kept in mind at all times, as well as the University’s values set out in its Strategic Plan:  academic freedom, accountability, collegiality, equity and inclusion, excellence, innovation, integrity, respect, and sustainability.

4.7 This Guideline is not intended to replace University-level policies or procedures, or more detailed College or Program-specific policies or guidelines.  

4.8 Should a concern arise respecting individual conduct as it relates to the Rady Faculty of Health Sciences community, learners can report concerns to any of their teachers, preceptors, course/rotation directors, administrative staff members, Department Heads, Associate Deans within their program, Student Affairs or Student Services at Bannatyne Campus representatives, including Student Advocacy, according to personal comfort and preference. The “Speak Up” button can be utilized by RFHS learners.  

Faculty members and staff may contact Human Resources or their union representatives. The University’s Office of Human Rights and Conflict Management is a resource available to all University members. 

If the matter involves a potential privacy breach, the Access and Privacy Office shall be notified in accordance with the Access and Privacy Policy.

4.9 In the unlikely event that a complaint is filed following a learner led event, the consequences may be dependent upon the applicable University policy, bylaw, collective agreement, professional standard, or legislation that may have been breached, as well as on the circumstances, on the seriousness of the breach, and any mitigating factors.  

The applicable policy or other governing document should be referenced; however, the following list provides examples of measures and is not meant to be exhaustive nor necessarily represents a progression of measures:

a)    A letter of apology;
b)    Attendance at educational session(s);
c)    Attendance at coaching session(s);
d)    Academic consequences such as remediation, probation, notation on the performance record, dismissal/expulsion from the Program/College/RFHS;
e)    Termination of employment or academic appointment.        

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5. GUIDELINE CONTACT

Please contact your respective dean with questions regarding this document.

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6. APPROVAL

These guidelines were approved by the RFHS Faculty Executive Leadership Team on April 19, 2023.

Policy name	Mobile/wireless device policy
Application and scope
Approved date	May 15, 2018
Review date	March 31, 2023
Revised date
Approved by	Council of Deans, Rady Faculty of Health Sciences

PURPOSE

To provide a consistent process for the eligibility, approval and tracking of mobile/ wireless devices or portable electronic devices and their respective charges on operating funds. Any exceptions to this policy require written approval of the Director of Finance, RFHS.

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DEFINITIONS

Mobile/ Wireless Devices - includes cellular/ smartphones, laptops, tablets, and other similar devices.

Examples of devices:

Cellular/ Smartphones, such as iPhone, blackberries, Samsung, Sony, Nokia, etc.

Laptops such as MacBook, Samsung, IBM, Asus, etc. Tablets – iPad, Samsung, Asus, etc.

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STATEMENT OF POLICY

1. Device Approvals

Purchase of cellular devices/smartphones may be approved by the individuals one-over-one and Director of Finance using U of M operating funds, prior to submission to IST, for those staff or faculty who meet all the following criteria:

a. They hold a position at the level of Dean, Vice Dean, Associate Dean, Department Head, Director or Manager;

b. The majority of their annual income is derived from the position in (a) above;

c. There is an essential business need/ justification specific to the individual’s role in the

College or Faculty including:

i. Significant amount of time is spent out of the office for various work related reasons.

ii. Due to the nature of their position they are required by the respective Dean to respond to urgent email or phone messages.

2. UMFA Approvals

Cellular/ smartphone contracts for UMFA members must follow Article 27 of the Collective Agreement and there must be sufficient budget in the respective Travel and Expense fund to cover the expenses. Purchase approval for both the phone/upgrades & monthly plan will follow the same process of one-over-one approver & the Director of Finance, prior to submission of the request to IST.

i. Turn data roaming off when you don’t need to check email/ internet.

ii. WiFi services should be used as often as possible to reduce these costs and manage the data plan for the mobile device. Most hotels offer WiFi free of charge or for a nominal fee, which allows the individual to check emails and download files or information.

iii. Turn off applications that leverage GPS, such as Maps, Weather, etc.

6. Overages

Wireless devices with a monthly invoice based on usage will be monitored by RFHS Finance Office. Individuals whose monthly charges exceed the normal monthly charge by $10 or more will be responsible for reimbursing the University for the entire overage. Individuals who exceed their travel packages may be personally responsible for the overages.

7. Inventory

An inventory of mobile/ wireless devices with monthly charges must be kept by the respective College Senior Financial Officer and reviewed annually.

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POLICY CONTACT

Director of Finance, Rady Faculty of Health Sciences

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CROSS REFERENCES

This policy should be cross-referenced to the following relevant Governing Documents:

Mobile/ Wireless Devices

Use of Computer Facilities Policy and Procedures – November 2013

Travel and Business Expense Claims Policy and Procedures – December 2017

Custody and Control of Electronic Devices and Media Policy and Procedures – June 2015

Policy name	Rural and remote Manitoba learner travel policy
Application and scope	Learners of the Rady Faculty of Health Sciences and its Colleges, University of Manitoba
Approved date	September 7, 2022
Review date	Five (5) years from revised date
Revised date	February 28, 2024
Approved by	Executive Team, Rady Faculty of Health Sciences: February 28, 2024 Dean’s Council, Rady Faculty of Health Sciences: September 7, 2022

1. PURPOSE

1.1. The purpose of this policy is to identify what is considered out-of-town rotation (placements), and to outline the parameters surrounding travel, accommodations, and reimbursement for expenses during those learner placements.

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2. DEFINITIONS

2.1. Primary Location: The primary location is the city or town where the learner is based and spends most of their academic time. For example, a learner with a primary location in Selkirk may choose not to reside in Selkirk for several reasons and instead chooses to reside in Winnipeg. A learner who chooses not to reside in their primary location will not be eligible for reimbursement of any expenses related to attending their primary location.

2.2. Out-of-Town: A location that is outside of the city limits of the learner’s primary location.

2.3. Out-of-Town Rotation (Placement): A location within Rural and Northern Manitoba, for which the learner has been assigned and/or approved to travel in relation to Rady Faculty of Health Sciences (RFHS) and its Colleges’ academic education.

2.4. College/Program Directed: A location scheduled by RFHS and its Colleges as part of the academic schedule.

2.5. Learner Directed: A location selected and/or requested by the learner.

2.6. Block: Is 28 days in duration.

2.7. Block (post grad) or placement: Is one of thirteen (13) time intervals within each academic year. With the exception of Block one (1), Block seven (7) [Holiday Season break] and Block thirteen (13), all blocks consist of four (4) week intervals of training and are considered equivalent for the purpose of scheduling educational activities for trainees in the hybrid competency-based medical education model.

Block (other than post grad) or placement: A practicum placement in a program in Rady Faculty of Health Sciences that is a requirement for completion of the program. Length and requirements vary per program.

2.8 Designated accommodations: Accommodations arranged and booked through the Office of Rural & Remote Learner Experiences.

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3. ACCOMMODATIONS

3.1. Learners are expected to stay at designated accommodations locations when on out-of-town rotation (placements) unless these are confirmed to be unavailable at that time. Learners will not be reimbursed for accommodations booked on their own without pre-approval from the Office of Rural & Remote Learner Experiences.

3.2. Learners with specific commitments or obligations, such as family, children, pets may qualify for reimbursement. Pre-approval is required. Learner must contact the Office of Rural & Remote Learner Experiences for reimbursable amount and pre-approval prior to being eligible for reimbursement. Reimbursement amount is subject to review and change on an annual basis. Accommodations reimbursed only for commercial accommodations (e.g., hotel, motel, AirBnB).

3.3. Learners who decline designated accommodations in a given out-of-town location will be responsible for their own accommodation expense unless pre-approved.

3.4. Learners who choose to maintain an ongoing second residence within a community other than their primary location, will do so at their own expense, and reimbursement will not be provided in these instances.

3.5. If a learner chooses to stay with friends or relatives (non-commercial) instead of designated accommodations, the learner will be reimbursed for a daily amount of $7.14 per day, maximum of $200.00 per block (28 days) to cover a reasonable gift for the host family. Confirmation email from the host gift recipient and receipts required.

3.6. If a placement/rotation is longer than 12 consecutive weeks, pre-approval for accommodations is required.

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4. AIRFARE

4.1. Flights will be booked directly through the Office of Rural & Remote Learner Experiences and will coordinate with the learner’s placement.

4.2. Any changes to flights will be done through the Office of Rural & Remote Learner Experiences. In instances where that is not possible (such as after business hours and on weekends):

4.2.1.  Change fees, incurred at the request of the College/Program, will be reimbursed as incurred.

4.2.2.  Costs incurred as a result of flight cancellations due to weather will be reimbursed as incurred.

4.2.3.  Additionally, mandatory courses or attendance back to Winnipeg will be reimbursed when approved by college (Education or Program Director).

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5. MILEAGE

5.1. Mileage to and from out-of-town rotation (placements), will be reimbursed at University of Manitoba (UM) approved rates as per the UM Travel Policy. If a learner is not scheduled to work during a statutory holiday additional mileage is eligible for reimbursement with pre-approval. Commute to nearby communities relating to the out-of-town rotation (placement) is eligible for reimbursement. Trips to visit family/friends mid-placement are not eligible for reimbursement.

If a learner decides to commute to the out-of-town rotation (placement) rather than accept accommodations it is considered self-directed, and mileage will not be reimbursed.

5.2. Only incremental kilometers driven above 40km one way from personal residence or teaching site (which ever is less) to placement may be claimed.

For example, if the one-way distance from the teaching site to placement is 80km and is 50 km from learners home the learner would be reimbursed 10 km.

5.3. Any additional mileage not representing the most direct route to the placement, and corresponding return to the primary location or home residence will not be reimbursed.

5.4. For northern or remote placement, mileage is reimbursed up to a maximum of the cost of a flight.

5.5. An additional round trip is covered if attending a mandatory academic activity.

5.6. Kilometers within the community of the placement are not reimbursable without pre-approval.

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6. TAXIS/SHUTTLES

6.1. Taxi and shuttle services while in community to get to and from accommodations and practice sites need pre-approval. To claim – receipts and proof of pre-approval is required.

6.2. If learner is claiming mileage, then they should be driving to and from the practice site and claim mileage (section 5).

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7. MEALS PER DIEM

7.1. Learners on rotations/placements above the 53rd parallel are eligible for a $200.00 per week for meals per diem. Learners who are in communities that qualify for this benefit will be notified by the Office of Rural & Remote Learner Experiences (effective April 1, 2024).

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8. NON-REIMBURSABLE EXPENSES

8.1. Return travel during vacation or mid-placement (except as outlined in 5.5).

8.2. Costs of car rentals, taxis, parking, or other transportation costs incurred (except as noted in 6.1).

8.3. Costs related to individuals other than the approved learner, including family and pet travel or accommodations (expect as noted in 3.2 with pre-approval).

8.4. Change fees for missed flights or made at the request of the learner.

8.5. Additional local travel costs incurred while in placement (except as outlined in 5.6).

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9. OTHER FACTORS

9.1. If at any time the learner feels either air travel or road travel is unsafe due to weather factors, they may decide to decline boarding an aircraft or engaging in road travel on a particular day. In such cases the learner is to contact the Office of Rural & Remote Learner Experiences immediately to inform them of this decision. Alternate arrangements may then be made between the Office of Rural & Remote Learner Experiences and learner at that time.

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10. CLAIM SUBMISSION

10.1. To be eligible for reimbursement, an expense claim must be submitted following the University of Manitoba procedure within 30 days of the end of the out-of-town rotation (placement).

Any extension of this deadline will only be considered in the event of extraordinary circumstances and requires express written approval from their Program Coordinator/Administrator.

10.2. Submissions need to include:

10.2.1. RFHS Expense Claim Form (fully completed)

10.2.2. RFHS Travel Log (number of trips/distances can be used on log)

10.2.3. All receipts

10.2.4. Pre-Approval Form – if claiming taxi’s/shuttles, accommodations

10.2.5. Email confirmation from the recipient that the host gift was received must be included.

10.3. Claims are to be submitted via email to Rady.RuralRemotePlacements@umanitoba.ca

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11. REFERENCES

11.1. RFHS Expense Claim Form

11.2. RFHS Travel Log

11.3. Pre-Approval Form

11.4. UM Travel Policy & Procedures documents

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12. POLICY CONTACT

12.1. Contact the Office of Rural & Remote Learner Experiences at Rady.RuralRemotePlacements@umanitoba.ca with questions regarding this policy.

Guideline name	Travel and business expense guideline
Application and scope
Approved date	May 1, 2018
Review date	March 31, 2023
Revised date
Approved by	Rady Faculty of Health Sciences Council of Deans

PURPOSE

To provide guidance or more restrictive constraints over specific business and/or travel expenditures Travel and Business Expense Claims Procedure below for the Rady Faculty of Health Sciences. In each instance the section in the Procedure in which guidance is being provided or to which the constraint applies will be indicated. The following guideline applies regardless of ultimate source of funding.

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DEFINITIONS

Hospitality – Food and/or beverages for events where there is more than one person. An individual travelling on University business and claiming their individual meal is not considered hospitality.

The University has an exclusive agreement with Aramark with respect to providing catering services within U of M space. Therefore, Aramark must be used for all Hospitality or Special Events held within U of M space unless a Catering Waiver has been approved by Dining Services.

Special Events – Hospitality that involves meeting with potential donors or alumni as well as milestone events such as College Anniversaries where there may be dignitaries present. Additional events maybe approved by the Senior Financial Officer of each representative College.

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GUIDELINE

1. Meals while traveling (Section 2.20)

a. Actual costs (meals with receipts) will have the following caps:

Region of travel	Breakfast	Lunch	Supper	Per diem
Canada	$15	$15	$30	$60
USA/Africa	$20	$20	$40	$80
Asia/Latin America/Oceania	$20	$20	$50	$90
Europe/Caribbean	$25	$25	$60	$110

b. To avoid the requirement to submit receipts the daily per diem allowance can be claimed, and would be considered the daily maximum. If you plan a mix of actual receipts and per diem within a given day, the daily per diem will remain the maximum total claim for that day.

2. Travel Exceptions to the Travel and Business Expense Policy (Section 2.3)

a. For exceptions to the U of M Travel and Business Expense Claims Procedure; airfare using personal cards & expenses 12+ months old, all supporting documentation must accompany the exception request form provided by U of M Travel Services. These should be submitted to the Director of Finance for review and RHFS Dean signature. It will be the submitters responsibility to obtain VP approval following College signoff.

b. Exceptions to this guideline can be requested via email from the Director of Finance, Rady Faculty of Health Sciences. A special exception form is not required.

3. Hospitality/staff events (Section 2.21)

a. All hospitality is to be pre-approved at the following levels via the RFHS Hospitality approval form (note the meal max per person of $75) attached:

i. Senior Financial Officer (SFO) – up to $40 per person (including tax and gratuity)

ii. College Dean – over $40 and up to $75 per person (including tax and gratuity) following initial review and approval by the SFO

b. CPD events where the individual registrant fees cover the entire cost of the event including the meal do not require pre-approval via the Hospitality form, and can be approved by the one-over-one within the College/Department.

c. Research related hospitality/staff events must be approved by the respective FOP Grant Accountant (email will suffice), and included in the submission to the SFO.

d. Approval will not be granted for internal Faculty/Staff/Student meetings, Journal Clubs or Grand Rounds. An exception may be granted by the SFO in specific cases where funding is provided by external partners specifically for this purpose.

e. Recruitment & Visiting Professors dinners are limited to a maximum of 4 people in attendance (3 U of M Faculty plus the guest). A reasonable amount of alcohol may be considered for these events, as discussed with your SFO. Exceptions for number of attendees may be considered for a Dean recruitment.

f. Meals with students during Recruitment & Visiting Professors visits are not considered an acceptable hospitality, and any exceptions will need to be approved by the SFO.

g. Faculty/Staff/Resident planning retreats & events are limited to one event per year for each College or Department. Holiday parties are not considered an acceptable event, as these are provided on a Faculty and/or College level for all Faculty/Staff.

h. Formal graduation dinners must be student funded. Colleges or departments are permitted to make a monetary contribution to these events if their budget allows. Refreshments and snacks may be permitted following College convocation ceremonies when they are not included in the University convocation ceremony.

i. Retirements – a small cake and coffee party is permitted, any larger event requires ticket sales or personal/private funding.

j. CaRMS Interviews – the maximum University approved funding per person will be communicated annually from the Deans office, Max Rady College of Medicine.
 
k. Alcohol may be permitted at Special Events, as pre-approved by the SFO & College Dean. Total expenses are to remain within $100 per person (inclusive of food, beverages, taxes, tip, etc.).

l. Alcoholic beverages are not an allowable expense except as noted in (e) and (k) above and under no circumstance is alcohol to be charged to research funds. Use of a cash bar is acceptable and recommended for events not otherwise approved.

4. Conferences (Section 2.3)
Limited to one (1) per person, per fiscal year, for management and other senior administrative staffing. In situations were other staff are the most appropriate attendees, this would be considered appropriate when requested by a one-over-one with management agreement. Conferences are not to be used to address personal professional development. All attempts are to be made to send the minimum number of individuals to any conference, with the expectation of information gained being disseminated to additional staff at a later date.

5. Parking (Section 2.45)
Airport parking charges while traveling on University business will be permitted up to a maximum of $100/trip. Any amounts exceeding the maximum should be approved by the SFO with justification provided regarding the most economical travel vs taxi transportation to and from the airport.

6. Caregivers (Section 2.49)
Claimants requiring an accompanying caregiver while traveling may be considered following approval of the one-over-one in conjunction with the Director of Finance.

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GUIDELINE CONTACT

Director of Finance, Rady Faculty of Health Sciences

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CROSS REFERENCES

This guideline should be cross referenced to the following relevant Governing Documents:

Travel and Business Expense Claims Policy and Procedures – December 2017

Please provide a completed Hospitality Event Pre‐Approval Form to Rady FHS Finance, who will submit for final approval and return via email.

Policy name	Utilization of standardized patients resources, bookings, cancellations
Policy number	SP-1
Application and scope	All units or users utilizing standardized patients
Approved date	September 2022
Review date	Five (5) years from approval date
Revised date
Approved by	CLSP Steering Committee August 2022 and RFHS Deans Council September 2022

BACKGROUND

The incorporation of Standardized Patients (SPs) supports a variety of clinical educational activities across RFHS and other users.

Incorporation of Standardized Patients (SPs) into clinical learning requires consideration of additional responsibilities for all program users, such as – but not limited to - reasonable scheduling timeframes, deadlines for submitting case files, and providing meals where SPs cannot leave the scenario environment, etc.

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1. PURPOSE

To standardize the process by which SP resources within CLSP are requested and utilized. To ensure fair and equitable recruitment and treatment of SPs and to balance the fiscal responsibilities thereby incurred.

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2. DEFINITIONS

Staff of the Standardized Patient Program can fulfill many roles and scopes to meet user needs, including:

Physical Exam Models (PEMs)

PEMs do not reproduce histories or findings, but allow their own bodies to be used for clinical examination / demonstration, not including genital and / or breast exams (see SETA for sensitive exams)

Standardized Patient (SP) 

SPs simulate a set of symptoms and medical conditions accurately for specific scenarios for both formative events as well as in summative events to assess learners’ clinical and communication/interpersonal skills.

Standardized Client (SC) 

Healthcare professions / educators that use the term "client" rather than "patient" typically use this designation rather than “SP.”

Standardized Health Professionals (SHPs)

We recruit SHPs from the same, similar, or adjacent healthcare professions represented by the event to draw upon their professional training for the purposes of simulation.

Sensitive Exam Teaching Associates (SETAs) 

SETAs teach the clinical and communication skills necessary to conduct:

• pelvic and/or breast exams for female anatomy (CTAs)
• genital / rectal exams for male anatomy (MUTAs)

SPares 

SPares (or back-ups) are trained to the same degree as any other SC, SETA, SHP, or SP in the same competencies, they agree to wait on site in case scenario/SP backup is required.

Event Staff 

SPs recruited as staff contribute to the administration of events as timekeepers, hall monitors, or invigilators, or other duties as required.

Cancellation 

A request from the requesting user group to not proceed with a planned event before event start

Core Competencies

Standardized Patients (SPs) typically operate within three (3) core competencies:

• Facts, wherein an SP learns and accurately reproduces the details of a particular role
• Findings, wherein an SP learns and accurately reproduces emotional, psychological, and / or physical symptoms
• Feedback, wherein an SP provides well-considered, constructive written and / or verbal feedback regarding candidates’ performances

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3. POLICY STATEMENTS

Adequate notice

Please submit requests for SP service no less than six (6) working weeks prior to any event exclusive of any university closures.

Requests submitted after the six-working week deadline receive case-by-case consideration, however support cannot be guaranteed.

Please provide case information (if required) as close as possible to the date the service request is submitted. To support quality SP training and event planning, final drafts must be approved no less than 10 business days before first event date.

For requests received with six weeks of notice, the SP program will strive to deliver recruitment completed by the four-week mark, or two weeks from event date.

For requests received with less than six weeks’ notice and accepted for support, best efforts will be made to complete recruitment before the event date.

If the information in the request form is complete, you will receive confirmation within 48 hours of submission.

If we are unable to fulfill a request, we will provide notice within five (5) working days.

All requests received six weeks + before the first event date receive first consideration. Preparation and planning will proceed chronologically by date of event. Should there be a conflict, we will prioritize events in accordance with the list of prioritizations set out in the CLSP Booking Policy.

Cancellation

Users must inform the SP department of intent to cancel an event with as much notice as possible.

Users must provide notice of cancellation of events or shifts no less than three business days prior to avoid cancellation costs. Notice of event cancellation provided with less than three business days will require that confirmed SPs be paid three-hour minimums at the applicable rate (per the Rate of Pay procedure).

We will accommodate cancellations with less than three business days’ notice only in legitimate emergencies, or unforeseen and uncontrollable circumstances at the discretion of the CLSP Manager and/or Director.

Rates of Pay, Breaks

SP payrates and break entitlements will be determined by the RFHS and maintained in a separate procedure document. These items will be maintained in accordance with UM policies, and Manitoba Labour law.

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4.0 SP MEALS

Events requiring sequestration or that restrict the movement of SPs during an event will require event requestors to provide appropriate meals, namely:

Events less than four hours in duration – one 20-minute break with light refreshments

Events greater than four hours in duration – two 20-minute breaks with light refreshments and a 30-minute meal period with a provided substantial mid event meal.

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5.0 SUBMITTING A REQUEST AND PROVIDING SCENARIO DOCUMENTATION

5.1 All requests for booking SPs must be completed with the online request form.

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6.0 SAFETY

6.1 In keeping with University of Manitoba’s Respectful Workplace Policies, we reserve and recognize the right of SPs to recuse themselves from participating in activities that make them feel unsafe and / or uncomfortable at any point. Please refer to the SP Safety policy for further information. The SP Educator managing your event will discuss this caveat and discuss possible spare SPs on hand to reduce any chance of session interruption.

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7.0 REFERENCES

7.1 Online SP Request Form 

7.2 University of Manitoba Holiday Closure Dates

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8.0 POLICY CONTACT

Please contact the Director, CLSP with questions respecting this policy.

Policy name	Video and Audio Observation of Clinical Encounters for Learning Assessment Purposes
Application and scope	Staff, faculty members and learners of the Rady Faculty of Health Sciences and its colleges and programs
Approved date	March 22, 2024
Review date	Five (5) years from approval date
Revised date
Approved by	Executive Leadership Team, Rady Faculty of Health Sciences; Secretary’s Office - FYI

1. BACKGROUND AND SCOPE

1.1 Direct observation of a learner by a preceptor is required to assess a learner’s progress and performance in their educational program as required by accrediting bodies.  At times, live-feed video or audio observation may be undertaken to assist with such assessment.

1.2 This policy sets out the use of video and audio observation, the process and requirements by which it should occur, and clarify consent requirements and procedures.

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2. DEFINITIONS

2.1 Learner is an individual who is registered in a pre-licensure health professional program of the Rady Faculty of Health Sciences (RFHS) at the University of Manitoba (UM).

2.2 Preceptor means the faculty member charged with supervision and assessment of a particular learner

2.3 Express Consent means permission given directly either verbally or in writing

2.4 Patient is an individual who is receiving health care services

2.5 PHIA means the Personal Health Information Act

2.6 FIPPA means The Freedom of Information and Protection of Privacy Act

2.7 Private Site Partner Facility means an office, clinic or other facility in which health care service is provided to patients and in which RFHS learners attend for clinical education, that is privately owned and operated 

2.8 Health Region Partner Facility means a hospital, psychiatric facility, or other facility in which health care is provided to patients and RFHS learners attend for clinical education, that is owned and operated by Shared Health, the Winnipeg Regional Health Authority (WRHA), or other health region facilities.

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3. POLICY AND PROCEDURE STATEMENTS

3.1 Video or audio observation of a learner’s clinical encounters is utilized to allow for an organic clinician-patient interaction either on a periodic or remedial basis and is one assessment method identified by a preceptor to assess a learner.

3.2 Throughout their educational program, learners are required to complete clinical placements at partner facilities to satisfy the clinical portions of their educational programs.  Partner facilities are encouraged to allow for video and audio observations to assist with assessment of Rady Faculty of Health Sciences learners.

3.3 Sites that are approved by the department to equip their facilities with video and audio equipment must engage with RFHS IT to ensure that the spaces designated for observation are appropriately equipped and in compliance with applicable legislation such as PHIA and FIPPA as well as in accordance with IT standards.

3.4 The department must ensure that for all Partner Facilities:

• All spaces designated for observation must be equipped with hardware/software approved by UM RFHS IT and installed by a vendor as arranged by the department. 
• The department is responsible for infrastructure support including network and backend operations, the maintenance, security, and operation of equipment, and for ensuring provision of user access to live stream in accordance with Appendix A.  Health Region Partner Facilities should escalate network related issues to Digital Health, UM Central IST or local IT based on department IT support agreement.
• The department will conduct an annual auditing process and is responsible for the submission of the audit report to RFHS IT as outlined in the IT Audit Standard.
• Each clinical exam room equipped with hardware/software for the purposes of observing clinical encounters via live feed video for learning purposes shall have highly visible signage indicating same and that observations are only made with express consent and are not recorded.
• Cameras must be covered when not in use.

3.5 Procedure and requirements for undertaking video or audio observation:

1. The preceptor will indicate to the learner whether video or audio observation is to be utilized.
2. It is the learner’s responsibility to obtain and document patient express consent in their medical record prior to the clinical encounter. Verbal consent without documentation in medical record is not sufficient.
3. Under no circumstances should a patient encounter be viewed without the express consent of that patient, parent/guardian in the case of a child, or by a person permitted to exercise the rights of the patient.
4. The learner shall introduce themselves to the patient and name their preceptor.  They should explain that the preceptor has requested to observe the encounter by live feed video or audio for learning purposes.  The learner should ask if this is ok, answer any questions and explain that they can opt out at any time without impact to the quality of health care being received.
5. Should consent be declined or at any time withdrawn, the camera should be disabled and covered, and the learner must document in the patient chart. The preceptor may follow up with the patient to discuss further.
6. As the content of clinical encounters can vary significantly from visit to visit, consent should be obtained prior to each visit.  For visits regarding a single theme (e.g., psychotherapy), it would be acceptable to obtain consent for multiple visits for that theme.  In cases where a patient has provided ongoing consent for multiple visits, learners should confirm consent at the start of each encounter and advise that consent can be withdrawn at any time.
7. All video and audio observations for learning purposes are to be live stream only, and no recording shall be created of the clinical encounter. 

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4. REVIEW AND EFFECT ON PREVIOUS STATEMENTS

4.1 The Review Date for this Policy and Procedure is five (5) years from the date it is approved by the approving body.  In the interim, this document may be revised or repealed if:

(a) The Dean, Rady Faculty of Health Sciences & Vice-Provost (Health Sciences), with appropriate approvals, deems it necessary or desirable to do so;

(b) It is no longer legislatively or statutorily compliant; and/or

(c) It comes into conflict with another governing document of the RFHS or the University of Manitoba.

4.2 If this document is revised or repealed, any related Rady Faculty of Health Sciences documents shall be reviewed as soon as possible to ensure that they comply with the revised document, or are in term revised or repealed.

4.3 This Policy supersedes all previous governing documents dealing with the subject matter addressed in this document.

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5.REFERENCES

5.1 Freedom of Information and Protection of Privacy Act (FIPPA)

5.2 Personal Health Information Act (PHIA)

5.3 Shared Health Security & Storage of Personal Health Information policy

5.4 WRHA guidance on the Personal Health Information Act (PHIA)

5.5 Shared Health Audio, Video and Photographic Recordings policy

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6. POLICY CONTACT

Please contact Rady Faculty of Health Sciences IT director with questions regarding this document.

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Appendix A

IT audit standard: Audio-video in clinical setup

Objective

The audit standard aims to ensure the secure, compliant, and ethical use of audio and video data within clinical settings, maintaining patient confidentiality, data integrity, and compliance with regulatory standards.

AUDIT CRITERIA

1. Compliance Verification:

• Assess: Verify adherence to established audio-video policies and procedures.
• Audit focus:
  • Review documented consent forms, ensuring they align with recording scenarios.
  • Check access logs and policy compliance records for alignment with authorized recording instances.

2. Data storage and encryption:

• Assess: Evaluate security measures for data storage and encryption.
• Audit focus:
  • Review encryption protocols to ensure data security during storage and transmission.
  • Check the effectiveness of access controls in safeguarding recorded data.

3. Access controls and permissions:

• Assess: Review access controls and permissions for audio-video data.
• Audit focus:
  • Verify role-based access controls for limiting data access to authorized personnel.
  • Assess user permissions and authentication methods to prevent unauthorized access.

4. Training and awareness:

• Assess: Evaluate staff training and awareness regarding audio-video policies.
• Audit focus:
  • Review training records to ensure staff have received appropriate training on policy guidelines.
  • Assess the understanding of policies and guidelines through interviews or surveys.

5. Regulatory compliance:

• Assess: Ensure compliance with relevant regulatory requirements (e.g., PHIA).
• Audit focus:
  • Review policies against regulatory standards, ensuring alignment with patient data protection laws.
  • Check audit trails and documentation for compliance measures.

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AUDIT PROCESS

1. Pre-audit preparation:

• Gather documentation: Collect policy documents, consent forms, access logs, and training records.
• Assessment of risks: Identify potential risks associated with audio-video data handling and storage.

2. On-site audit activities:

• Document review: Review policy documents, consent forms, and access logs.
• Technical assessments: Perform assessments of data storage, encryption, and access controls.

3. Audit reporting:

• Findings: Summarize findings and areas of compliance and non-compliance.
• Recommendations: Provide actionable recommendations for improvement or corrective actions.
• Risk assessment: Document identified risks and their potential impact.

4. Follow-up actions:

• Corrective actions: Outline steps for addressing non-compliance issues.
• Monitoring plan: Establish a plan for monitoring and follow-up audits.
• Escalation procedures: Detail procedures for addressing critical issues.

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AUDIT DOCUMENTATION:

• Audit report: Detailed report outlining findings, recommendations, and action plans.
• Supporting documentation: Attach policy documents, consent forms, access logs, and audit trails.
• Risk register: Document identified risks and proposed mitigation strategies.

Roles and responsibilities:

1. Audit sponsor/owner: (department heads)

• Responsible for initiating and overseeing the entire audit process.
• Ensures that the audit aligns with Rady faculty of health sciences and university of Manitoba’s regulatory requirements.
• Approves the audit plan and any necessary resources.
• Designate an Audit Coordinator within the department that oversees the audit process and develop an audit team.
• Compiles findings into a comprehensive audit report.
• Presents the report to Rady IT.

2. Audit coordinator: (assigned by the department heads to coordinate the audit process)

• Coordinates the overall audit process.
• Develops the audit plan, including scope, objectives, and methodologies.
• Assigns tasks to audit team members.
• Manages communication with relevant stakeholders.

3. Audit team: (Include individuals from respective departments as selected by the audit coordinator/department head)

• Conducts the actual audit of clinical IT systems.
• Evaluates controls and processes related to clinical data integrity, security, and compliance.
• Identify and documents findings.
• Brings clinical expertise to the audit, understanding the specific requirements of healthcare environments.
• Assists in evaluating the clinical relevance and accuracy of IT systems.
• Focuses on assessing the security measures in place to protect clinical IT systems and patient data.
• Identifies vulnerabilities and recommends security improvements.
• Ensures that clinical IT systems comply with relevant laws, regulations, and industry standards.
• Keeps track of changes in compliance requirements.

4. IT department: (Rady IT)

• Ensures that the audit process follows established protocols and standards.
• Reviews audit documentation and reports for accuracy and completeness.
• Identifies opportunities for process improvement based on audit findings.
• Compile the Recommendations on audit report and submit it to Privacy Access Office and other relevant stakeholders.

5. Privacy and Access Office:

• Provides advice related to data privacy, confidentiality, and regulatory compliance.
• Assists in interpreting and addressing compliance aspects of the audit.

It is important to note that the roles and responsibilities may vary based on the size and structure of the department, as well as the specific requirements of the clinical systems being audited.

Prevention of Learner Mistreatment Policy (Professionalism Office, Max Rady College of Medicine, possible expansion to RFHS)

The Professionalism Office may receive a complaint through the policy that involves an individual outside of University jurisdiction (such as at a clinical learning site). The Associate Dean, Professionalism, will work with the CEO or delegate of that site to address the matter. In some cases, joint investigations occur.

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Agreements with Individuals/Sites (e.g. Learner Placement Agreement; Independent Contractor Agreement; GFT Agreement)

Certain agreements may place professionalism responsibilities on individuals or entities. For example, the template learner placement agreement states that learners will be placed in a professional and safe work and learning environment. It also allows learners to be removed from a site. A professionalism issue could be addressed through this avenue.

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Shared Health Joint Council / College Subcommittees

The Joint Council and its College Subcommittees are intended to be an avenue to address any professionalism issues against learners. This might involve members of a clinical learning site.

Collective Agreement Process (Labour Relations/Human Resources)

Jurisdiction: Faculty or staff that are part of a bargaining unit if there is a breach of their collective agreement. A breach is dependent on the specific wording in the collective agreement.

Application: To faculty or staff part of the collective agreement. Responsibility: Labour Relations/Human Resources, University of Manitoba.
Appeal: An appeal proceeds in accordance with the appropriate grievance process defined by the applicable collective agreement.

Human Resources Policy/Employment Standards (Human Resources)

Jurisdiction: Faculty or staff excluded from a bargaining unit, if there is a breach an employment agreement, human resources policy or employment standards law. A breach is dependent on the specific wording in the policy/employment law. Application: To faculty or staff of the University of Manitoba, excluded from a bargaining unit. Responsibility: Human Resources, University of Manitoba.

Appeal: An appeal mechanism is set out in The Appeals by Academic or Support Staff excluded from Bargaining Units Policy.

Responsibilities of Academic Staff with regard to Students Policy (UM)

Jurisdiction: To set out the responsibilities, and discharge of responsibilities, of Academic Staff with respect to students, including in their interactions with students.

Application: It applies to Academic Staff and Academic Administrators.

Responsibility: The Vice-Provost (Academic Affairs) is responsible for implementation of the policy. Appeal: It does not state what process applies should non-compliance occur.

Prevention of Learner Mistreatment Policy (Professionalism Office, Max Rady College of Medicine, possible expansion to RFHS)
Jurisdiction: To consider any intentional or unintentional, disrespectful treatment of a learner, trainee, or colleague that has or may have the effect of creating an intimidating, humiliating, hostile or offensive work or learning environment for learners in that circumstance.

Application: It currently applies across the Max Rady College of Medicine, however, the Director, Equity, Diversity and Inclusion is leading a Faculty-wide Learner Mistreatment working group to review Faculty-wide application.

Responsibility: The Associate Dean, Professionalism, Max Rady College of Medicine. Should Faculty-wide application of the policy occur, the query is whether this position/office should be made Faculty-wide to address matters under the policy.

Appeal: The avenue of appeal is dependent on the action taken under the policy.

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Respectful Work and Learning Environment Policy (Office of Human Rights and Conflict Management, UM)

Jurisdiction: To address complaints respecting discrimination, human-rights based harassment, personal harassment and sexual harassment.

Application: It applies to the University community, meaning all Board of Governors members, Senate members, Faculty/College/School Councils, employees, anyone holding an appointment with the University, students, volunteers, external parties, contractors and suppliers.

Responsibility: Office of Human Rights and Conflict Management, University of Manitoba.

Appeal: If the respondent is a member of a bargaining unit, an appeal proceeds in accordance with the appropriate grievance process defined by any applicable collective agreement. If the respondent is not a member of a bargaining unit, an appeal would proceed in accordance with The Appeals by Academic or Support Staff excluded from Bargaining Units Policy.

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Sexual Assault Policy (Office of Human Rights and Conflict Management, UM)

Jurisdiction: To address complaints respecting sexual assault/violence.

Application: It applies to the University community, meaning all Board of Governors members, Senate members, Faculty/College/School Councils, employees, anyone holding an appointment with the University, students, volunteers, external parties, contractors and suppliers.

Responsibility: Office of Human Rights and Conflict Management, University of Manitoba. There is a recently-opened Sexual Violence Resource Centre, but this is a resource/support centre.

Appeal: If the respondent is a member of a bargaining unit, an appeal proceeds in accordance with the appropriate grievance process defined by any applicable collective agreement. If the respondent is not a member of a bargaining unit, an appeal would proceed in accordance with The Appeals by Academic or Support Staff excluded from Bargaining Units Policy.

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Violent or Threatening Behaviour Policy (UM)

Jurisdiction: To establish a protocol for reporting and responding to issues of violence that occur with respect to University matters.

Application: It applies to the University community, meaning all Board of Governors members, Senate members, Faculty/College/School Councils, employees, anyone holding an appointment with the University, students, volunteers, external parties, contractors and suppliers.

Responsibility: University Security Services and Student/Staff Threat Assessment Triage Intervention Support team (STATIS), with review from the Vice-President (Administration).

Appeal: Where the individual is an employee, the discipline would be implemented pursuant to and in accordance with applicable legislation, common law, collective agreements, and University policies, procedures and bylaws. An appeal would be pursuant to that mechanism.

Referral to Regulatory Body (if Faculty/Staff is a Member)
Although not within University of Manitoba jurisdiction, a referral to the applicable professional regulatory authority may be advisable or required, depending on the status of faculty/staff as members of a regulatory authority, and the particular reporting obligations of the regulatory authority.

Professional Unsuitability Bylaw (Program/College)

Jurisdiction: A program’s Professional Unsuitability Committee reviews and makes recommendations regarding the suitability of a learner for the program, and may require the learner to withdraw from the program. Please note: Not all programs have professional unsuitability bylaws, and therefore this avenue is not open to all programs.

Application: The following programs within the RFHS have a Professional Unsuitability Bylaw/Committee:

• Bachelor of Nursing Program
• Undergraduate Programs of the Dr. Gerald Niznick College of Dentistry and School of Dental Hygiene
• Doctor of Pharmacy Program
• Bachelor of Midwifery Program
• Masters of Occupational Therapy Program

Responsibility: The Program/College, through the Program’s Professional Unsuitability Committee.

Appeal: To the University of Manitoba’s Senate Appeals Committee.

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Essential/Requisite Skills Policy / Bona Fide Academic Requirements (Program/College)

Jurisdiction: The document sets out the requisite skills and abilities for learners in the program, and may require a learner to withdraw from the program, if not meeting the requirements. Often, the requisite skills and abilities document has a requirement to conduct oneself in a professional manner and/or other professionalism requirements.

Application: The following programs have an Essentials/Requisite Skills policy/document or BFARs:

• Applied Health Sciences
• Bachelor of Midwifery Program
• Bachelor of Nursing Program
• Bachelor of Respiratory Therapy Program
• Biochemistry and Medical Genetics
• Community Health Sciences
• Dental Hygiene Diploma Program
• Doctor of Dental Medicine Program
• Doctor of Pharmacy Program
• Human Anatomy and Cell Science
• Immunology
• Masters in Oral and Maxillofacial Surgery
• Masters of Nursing, Nurse Practitioner Program, PhD in Nursing
• Masters of Occupational Therapy Program
• Masters of Physical Therapy Program
• Masters of Physician Assistants Program
• Masters of Science Genetic Counselling
• Masters of Science Pharmacy
• Masters of Science Prosthodontic Program
• Masters of Science Rehabilitation Sciences Program
• Medical Microbiology and Infectious Diseases
• Oral Biology Program
• Pathology Program
• Pharmacology and Therapeutics
• PhD Pharmacy
• Physiology and Pathophysiology
• Postgraduate Medical Education Program
• Preventative Dental Sciences
• Prosthodontics
• Surgery
• Undergraduate Medical Education Program

Responsibility: The Program is responsible to address any issues with requisite skills and abilities; this usually proceeds through the program to the Associate Dean, Director or Department Head responsible for the Program.

Appeal: Although not usually stated within the document, an appeal related to BFARs or Essential Skills would usually be considered an academic matter, and would go the Student Appeals Committee of the College or the Faculty of Graduate Studies. In some cases, the BFARs or Essential Skills of the program are referenced in matters that proceed through the “non-academic misconduct” route (see the Student Discipline Bylaw process below).

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Student Discipline Bylaw (UM)

Jurisdiction: To address academic misconduct and non-academic misconduct of learners. Inappropriate or disruptive behaviour includes unprofessional conduct.

Application: To all learners at the University of Manitoba.

Responsibility: The responsibility for discipline depends on the misconduct, and ranges from academic staff responsibility to the President. Tables 1 and 2 of the Bylaw set out the jurisdiction of the disciplinary authority.

Appeal: Appeals proceed in accordance with the Bylaw Appeal Procedure. Final decisions of a College/Program would proceed to the RFHS Local Disciplinary Committee and then to the University Discipline Committee, which is the final level of appeal within the University.

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Prevention of Learner Mistreatment Policy (Max Rady College of Medicine)

Jurisdiction: To consider any intentional or unintentional, disrespectful treatment of a learner, trainee, or colleague that has or may have the effect of creating an intimidating, humiliating, hostile or offensive work or learning environment for learners in that circumstance. In addition to addressing the processes under the Prevention of Learner Mistreatment Policy (complaints via the Speak Up button/process and compliments via the Keep It Up Button), the Associate Dean, Professionalism/Professionalism Office also reviews and addresses learner mistreatment student surveys and end of rotation evaluations, all which feed into the same system (Entrada) for tracking. This allows a centralized system to track all information relating to learner mistreatment, and provides for a denominator in tracking all incidents of learner mistreatment and capturing the data where no mistreatment is reported (i.e. answering “no” to the question). Referrals are made to the OHRCM if the matters falls under the RWLE Policy. Consultations occur with affiliated clinical placement sites, on an as-needed basis.

Application: The policy applies across the Max Rady College of Medicine. 

Responsibility: The Associate Dean, Professionalism, Max Rady College of Medicine.

Appeal: In cases where either the Complainant or the Respondent are dissatisfied with the Reviewer’s decision, that person must initate their appeal in writing to RFHS Dean or designate within 10 working days of the report and refer to the applicable University Policy, Procedure or Bylaw or collective agreement.

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Prevention of Learner Mistreatment Guidelines (Faculty of Health of Sciences)

Jurisdiction: Each College/IHP has jurisdiction to consider Learner Mistreatment matters not covered by other jurisdictions (please see Appendix A - Jurisdiction: Referrals and Review). Matters considered of a serious nature or involving alleged egregious behavior, are referred to the appropriate forum/body. For clarity, the Office of Professionalism will refer all reports respecting harassment, discrimination, or sexual violence, as covered by the University’s Respectful Work and Learning Environment Policy and Sexual Violence Policy, to the Office of Human Rights and Conflict Management. Cases involving sexual violence can also be referred to the Sexual Violence Resource Centre. If a referral is to be made to another body by the Office of Professionalism, the Complainant will first be notified.

Application: The guidelines apply to faculty, staff and learners of the Rady Faculty of Health Sciences and its Colleges.

Responsibility: Respective college, program and school leads.

Appeal: In cases where either the Complainant or the Respondent are dissatisfied with the Reviewer’s decision, that person must initate their appeal in writing to RFHS Dean or designate within 10 working days of the report and refer to the applicable University Policy, Procedure or Bylaw or collective agreement.

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Respectful Work and Learning Environment Policy (Office of Human Rights and Conflict Management, UM)

Jurisdiction: To address complaints respecting discrimination, human-rights based harassment, personal harassment and sexual harassment.

Application: It applies to the University community, meaning all Board of Governors members, Senate members, Faculty/College/School Councils, employees, anyone holding an appointment with the University, students, volunteers, external parties, contractors and suppliers.

Responsibility: The Office of Human Rights and Conflict Management, University of Manitoba.

Appeal: If the respondent is a learner, the appeal proceeds in accordance with the Student Discipline Bylaw and the Student Discipline Appeal Procedure.

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Sexual Assault Policy (Office of Human Rights and Conflict Management, UofM)

Jurisdiction: To address complaints respecting sexual assault/sexual violence.

Application: It applies to the University community, meaning all Board of Governors members, Senate members, Faculty/College/School Councils, employees, anyone holding an appointment with the University, students, volunteers, external parties, contractors and suppliers.

Responsibility: The Office of Human Rights and Conflict Management, University of Manitoba.

Appeal: If the respondent is a learner, the appeal proceeds in accordance with the Student Discipline Bylaw and the Student Discipline Appeal Procedure.

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Violent or Threatening Behaviour Policy (UM)

Jurisdiction: To establish a protocol for reporting and responding to issues of violence that occur with respect to University matters.

Application: It applies to the University community, meaning all Board of Governors members, Senate members, Faculty/College/School Councils, employees, anyone holding an appointment with the University, students, volunteers, external parties, contractors and suppliers.

Responsibility: University Security Services and Student/Staff Threat Assessment Triage Intervention Support team (STATIS), with review from the Vice-President (Administration).

Appeal: Where the individual is a student, the discipline will be implemented in accordance with the Student Discipline Bylaw and the Student Non-Academic Misconduct and Concerning Behaviour Procedure. Appeals proceed in accordance with the Bylaw Appeal Procedure. Final decisions of a College/Program would proceed to the RFHS Local Disciplinary Committee and then to the University Discipline Committee, which is the final level of appeal within the University.

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Referral to Regulatory Body (if Learner is a Member)

Although not within University of Manitoba jurisdiction, a referral to the professional regulatory authority may be advisable or required, depending on the status of learners as members of the regulatory authority, and the particular reporting obligations of the regulatory authority.

Program Council

The Interdisciplinary Health Program Council (IHPC) will be responsible for bringing recommendations on the academic content of the Bachelor of Health Sciences (BHSc) and Bachelor of Health Studies (BHSt) degree programs to the Rady Faculty of Health Sciences Faculty Council. The IHPC will deal with matters such as program orientation, course changes, and entrance requirements. All program changes will be approved by the IHPC before submission to the Rady Faculty of Health Sciences Faculty Council and Senate as required.

A. Membership:

1. Chair of the IHPC (Dean, Rady Faculty of Health Sciences or designate)

2. Dean, Faculty of Arts

3. Program Director appointed by the Dean, Rady Faculty of Health Sciences

4. Two representatives from each of the two partner faculties (Faculty of Arts and Rady

Faculty of Health Sciences), chosen using procedures internal to the respective faculties, from among full‐time professors, associate professors, assistant professors, lecturers, instructors I and II and senior instructors holding academic rank in the respective faculties

5. Two students, one each from the BHSc and BHSt degree programs elected by and from among the student body

6. Such others as may be authorized by the Chair of the IHPC, including Student Advisers and staff helping students with their programs (visitors, observers, etc.). These individuals would be non-voting.

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6. The quorum necessary for the transaction of business shall be one third of the total voting membership.

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E. Voting Procedures:

1. Voting privileges shall be restricted to members present at the meeting.

2. Motions to provide for other methods of voting require the consent of a majority of the members present and voting.

3. A simple majority is required.

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F. Committees:

Program Council shall determine:

1. The number and terms of reference of Committees.

2. Decisions of committees shall be recorded and forwarded to committee members.

3. The Chair is a member ex‐officio of any Council committee to which he/she is not specifically named.

4. Any committee may request a person(s) to sit in an advisory capacity.

5. Sub‐committee structure is left to the discretion of the committee.

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G. Rules of Order

1. In the conduct of its meetings, Council shall be guided by whichever authority is adopted by Senate, except in the case where Council adopts other specific procedures.

2. The Council may enact or amend standing rules and procedures for conduct of the affairs of the Council by a majority vote of those members of council present and voting at a meeting of council provided that five working days’ notice of the proposed enactment of amendment, and of the meeting date, is given.

The policy on Academic Progression, which includes details on:

• Good Academic Standing
• Academic Warning
• Academic Probation
• Academic Suspension, and 
• Required to Withdraw

Can be found in the current Academic Calendar. For quicker access, please refer to the index to locate the specific page for the College of Nursing.

View the Academic Calendar

Bylaw name	Professional unsuitability
Application and scope	Students of the Bachelor of Nursing Program, College of Nursing
Approved date	June 2020
Review date	Five (5) years from approval/revised date
Revised date	March 2, 2022
Approved by	College Council, College of Nursing: April 29, 2020, December 22, 2021 Senate: June 24, 2020, March 2, 2022

 

The purpose of this Bachelor of Nursing Program (“Program”) Professional Unsuitability Bylaw (“Bylaw”) is to set out the jurisdiction of the Program’s Professional Unsuitability Committee and procedures for professional unsuitability hearings. The purpose of the Professional Unsuitability Committee is to review and make recommendations regarding the suitability of a student for the Program.

For the purpose of this Bylaw, the “University” refers to the University of Manitoba.

For the purpose of this Bylaw, the “College” refers to the College of Nursing.

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1.00 Jurisdiction

1.01 General
The College of Nursing may require a student to withdraw from the Program pursuant to the procedures set out in this By-Law when the student has been found unsuited, on consideration of competence or professional fitness, for the practice of nursing. A student may be required to withdraw at any time throughout the academic year or following the results of examinations at the end of any academic term. This right to require withdrawal prevails notwithstanding any other provision in the College's Rules or Regulations. The Canadian Nurses' Association Code of Ethics, as the ethical basis for nursing in Canada, will be considered in every situation in which an inquiry is being held into the conduct of a student in the practice of nursing. Furthermore, in accordance with provisions of the Manitoba Human Rights Code, the College’s duty to reasonably accommodate the special needs of its students will be considered.

1.02 Grounds for Required Withdrawal
A student may be required to withdraw from the Program if the student has been found to be unsuitable for the practice of nursing, 

1. been found guilty of such conduct which, if participated in by a practicing registered nurse would result in suspension or expulsion of the practitioner from the practice of nursing or such other disciplinary actions available against a practitioner by the governing body of the profession;
2. practiced incompetently in any clinical setting;
3. jeopardized professional judgment through self-interest or a conflict of interest;
4. demonstrated behaviour with respect to other students, colleagues, faculty or the public which is exploitive, irresponsible or destructive;
5. acquired a criminal conviction which according to the established College processes was determined to be of such a nature as to bring disrepute to the profession, or by which in the opinion of the College, the student demonstrated poor judgment, lack of integrity or (other) unsuitability for the profession;
6. any health condition, the occurrence of which impairs essential performance required for the health profession;
7. been under the influence of alcohol, cannabis products, legal or illegal drugs which impair client care, any other professional activity, or any activity related to the practice of the nursing profession;
8. demonstrated unethical behaviour as specified by the Canadian Nurses’ Association Code of Ethics.

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2.00 Professional Unsuitability Committee (PUC)

2.01 There shall be established within the College a standing committee known as the Professional Unsuitability Committee (PUC) to hear and determine matters of competence and/or professional fitness for the practice of nursing.

Membership in the PUC shall be as follows:

Chair (non-voting, except in the case of a tie): a tenured faculty member or instructor to be appointed by the Dean, College of Nursing for a five (5) year term, which may be renewable.

Committee Members:

• three full time academic members of the College, elected by the Council of the College of Nursing, for a five (5) year term, which may be renewable;
• two students from the Bachelor of Nursing Program, College of Nursing; from either third year or fourth- year undergraduate and one graduate student, appointed by the respective student organizations, for a one year term, which may be renewable; and
• one full time academic member of the University College of the North, appointed by the Dean, College of Nursing; and
• one registered nurse external to the University of Manitoba, preferably with experience in dealing with disciplinary matters, to be appointed by the Dean, College of Nursing, for a five (5) year term, which may be renewable.

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3.00 Procedure

3.01 The Dean (or designate) shall:

i) refer matters, which in her/his opinion, involve conduct or circumstances described in Article 1.01 and 1.02 herein, to the PUC in a written report, setting out the name of the student involved, the alleged facts and the alleged ground(s) warranting withdrawal pursuant to section 1.01 and 1.02. In no circumstances will a referral be based solely on anonymous allegations or materials. Anonymous materials are defined as “authorship that has not been disclosed”.

ii) provide the PUC and student with the information which supports the request to assess, through a hearing, the student’s suitability for the profession of nursing.

3.02 Upon receipt of a request for a hearing into a student’s suitability for the profession of nursing, the PUC shall:

i) send a Notice of Hearing to the named student pursuant to section 4.01 by registered mail to the last known address of the student as found on the College’s records. At the student’s request, additional information may be sent by regular mail, email or facsimile;

ii) consider whether just cause exists to suspend the student while the matter is being determined and if so, to issue an interim suspension to the student;

iii) at all times act expeditiously to complete the hearing;

iv) determine whether any of the grounds requiring withdrawal under section 1.01 and 1.02 exist at hearing of the matter pursuant to this By-Law; and

v) make a disposition in accordance with section 6.00 herein.

3.03 Once a request for a hearing has been made to the PUC, the proceedings may continue notwithstanding that the student has subsequently voluntarily withdrawn from the Program, or has refused to participate in the proceedings.

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4.00 Notice to Students

4.01 The Chair of the PUC shall inform the student in writing, within five (5) working days of receipt of the request for a hearing, of the grounds for referral to the PUC, as well as the membership of the PUC and the date, time, and place for the hearing by the PUC of the matters set out in the referral.

4.02 The Notice from the Chair shall include a statement that if the allegations contained in the reference are established to the satisfaction of the PUC the student may be required to withdraw from the Program.

4.03 A faculty member shall not be disqualified from sitting as a member of the PUC hearing the matter by reason only that such faculty member has had previous contact with the student or has prior personal knowledge of the matter.

4.04 The student whose case is to be dealt with shall be permitted to challenge and thereby cause to be disqualified any member of the PUC. In such a case, the Chair would consider the grounds for the challenge and may replace the disqualified members pursuant to section 2.01. An academic member of the Program shall not be disqualified from sitting as a member of the PUC hearing the matter by reason only that such academic member has had previous contact with the student or has prior personal knowledge of the matter.

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5.00 Hearing Procedures

5.01 The student may provide a written response to the grounds. Such written response should be provided to the PUC and the Dean (or designate) within five (5) working days of the hearing date, or at the discretion of the Chair.

5.02 In addition to the written information, the Dean (or designate) may provide the PUC and student with additional relevant information and or evidence that supports the grounds for a hearing within five (5) working days of the hearing date, or at the discretion of the Chair.

5.03 The student may appear in person and may choose to be represented by a Student Advocate provided through the University, legal or other counsel. A student may request an additional support person who may accompany him/her to the hearing. This person will be considered an observer and will not be able to participate in the hearing process.

5.04 The Program and student may call relevant witnesses as needed. Written notice to each party of witnesses to be called by the other party shall be provided at least five (5) working days prior to the hearing date, or at the discretion of the Chair.

5.05 The hearing shall be closed to all persons except the members of the PUC, Program Representative, the student, the designated representative of the student, if any, and support person of the student, if any.

5.06 The student or her/his representative shall have the right to hear and to cross examine witnesses, to have access to copies of all documents submitted to the PUC for consideration at least five (5) working days prior to the hearing, to call witnesses and to submit other evidence.

5.07 The student shall not be required to give evidence but if the student elects to do so, then the student may be questioned by members of the PUC.

5.08 A quorum for the PUC shall be 4 members and the Chair as referred to in section 2.02 above.

5.09 A simple majority of the members hearing the matter is required for any finding or for the determination of the appropriate disposition of the matter.

5.10 The Chair of the PUC shall vote only to break a tie.

5.11 Members of the PUC shall be bound by confidentiality in respect of information received in Committee. Information will only be disclosed as is reasonably necessary to implement the investigation, the resolution or the terms of any disposition imposed, or as required by law.

5.12 The results of the hearing and the reasons therefore shall be conveyed in writing to the student, the Student Advocate, and/or the designated representative of the student where applicable, with copies to the Dean of the College of Nursing and the Associate Dean, Undergraduate Programs.

5.13 At the discretion of the Chair, hearings may be conducted in whole or in part via teleconference or other video/electronic means.

5.14 If the student is participating in a hearing via teleconference, the Chair may require the student to confirm that there are not recording devices present and only persons set out in section 5.03 are in attendance.

5.15 At the discretion of the Chair, hearings may be conducted at one of the three delivery sites of the Program (Winnipeg, The Pas, or Thompson) to allow the student to participate in person.

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6.00 Disposition of the Matter

6.01 The PUC shall, after hearing all the evidence, meet in closed session with its members only, to:

i) consider the evidence;

ii) make its findings using a balance of probabilities standard;

iii) if the allegations are proven, determine the appropriate disposition of the matter;

iv) if the allegations are not proven, dismiss the matter and/or make any other recommendation the PUC deems appropriate.

6.02 The PUC may make any disposition it deems appropriate in the circumstances. Without limiting the generality of the foregoing the following options, alone or in combination, are available:

i) determine that no further action be taken;

ii) allow the student to remain in the program and attach conditions prescribing future conduct by the student. Such conditions to remain in effect for any period of time the PUC deems appropriate;

iii) reprimand the student in writing;

iv) suspend the student from the Program for a specified period of 

v) require the student to withdraw from the Program, which withdrawal may attach conditions which must be fulfilled before any application for re-admission to the College can be considered;

vi) expel the student from the Program with no right to apply for re-admission to the College.

6.03 In cases in which the disposition of the hearing is one of iv, v, or vi as set out in section 6.02, the results shall be conveyed in writing to the Registration Consultant, College of Nursing who shall make the appropriate notation in the student’s transcript.

6.04 The student may request the PUC to consider removal of the notation from the transcript.

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7.00 Appeals

7.01 If the student wishes to appeal a disposition of the PUC, such appeal may be made to the Senate Appeals Committee in accordance with the procedures of that body.

7.02 In the event of an appeal, the implementation of any decision of the PUC may be suspended until the matter has been disposed of by the Senate Appeals Committee.

7.03 Notwithstanding the above, if the President of the University is satisfied that it is in the best interests of the University, the President may at any time make an order, subject to final disposition of the appropriate review authority, suspending the student from participating in any program of the University.

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8.00 Records

8.01 A record of any finding of professional unsuitability and/or disposition related thereto shall be kept on the student’s academic file within the Program and as required by the University. All information relating to the hearing before the PUC shall be kept in the office of the Associate Dean, Undergraduate Programs.

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9.00 Amendments

9.01This By-Law may be amended by the University’s Senate, or by Senate after approval of such amendment(s) by College Council.
 
Revisions approved by Senate: March 2, 2022
Approved by Senate: April 6, 2011
Revisions Approved by Senate: June 24, 2020

Academic progression

Effective September 2013 for Bachelor of Nursing program students:

Students are required to obtain a minimum of “C” grade in every letter grade course, a “Pass” in every Pass/Fail course, and a Program GPA of 2.5 to graduate. A final grade of “D” or “F” in a letter grade course or “Fail” in a Pass/Fail course taken to complete the degree requirement is considered a failure.

Academic assessments will be based on student performance in letter grade courses. The Term Grade Point Average (TGPA) will be calculated at the conclusion of each academic term in which the student has completed a minimum of 6 credit hours. Students who do not complete the minimum credit hours in one term will be assessed as “too few credit hours to assess”. These students will be assessed over two terms or more at the end of the term in which they reach the threshold of 6 credit hours.

The final term of the Bachelor of Nursing Program (NURS 4290/NURS 4580) will be excluded from assessment providing the student meets graduation requirements. Students are required to have a minimum Program GPA of 2.5 to be eligible for graduation.

Good academic standing

A student with a TGPA of 2.5 or higher will be assessed "College Minimum Met".

Academic warning

The first time a student’s TGPA drops below 2.5, the student will receive an Academic Warning. 

Procedure

Students who receive an academic warning will be given the option of remediation, and will be required to meet with a Nursing Student Advisor at least once during the following term of study.

Academic probation

the second time that a student’s TGPA drops below 2.5, the student will be placed on Academic Probation. A formal remediation plan will be mandatory for students on academic probation. 

Procedures

• The remediation plan will be developed by the Associate Dean (Undergraduate Programs) or designate with the active participation of the student.
• The remediation plan will be based on an assessment of the student’s current academic status and identified learning needs.
• The student may be required to repeat selected Nursing courses.
• The student may be required to repeat or register for the first time in selected non-Nursing courses (not elective courses). For example, students may be required or permitted to take or repeat select Statistics, Nutrition, or Native Studies course(s) from years 2 or 3.
• If any courses are repeated, the student will be subject to all academic regulations related to final grades in repeated courses and the number of failures allowed in any given course or sequence of courses in the Bachelor of Nursing Program.
• Students will be allowed to register in courses that they are required to repeat after students who are taking the course for the first time have had the opportunity to register and availability of space in the course can be confirmed.
• The student will be required to meet with a Nursing Student Advisor at least twice during the following term of study.
• Students on probation will not be permitted to register in any new nursing courses until they are removed from probation.
• If there are non-academic issues interfering with the student’s academic progress, the student will be required to make every effort to deal with and resolve those issues during the period of academic probation.
• Where indicated, a student will be referred to the student services unit for information and guidance. Any student subsequently registered with Student Accessibility Services and requiring accommodation by the College of Nursing will be referred to the College of Nursing Accommodation Team.

Academic suspension

The third time that a student’s TGPA drops below 2.5, the student will be placed on Suspension. Students who are suspended shall be ineligible to take any courses at the University of Manitoba or on a letter of permission for a minimum of eight and a maximum of 15 calendar months. 

Procedures

• The time period for the suspension actually served by the student is contingent on the program timetable and course availability.
• Students who wish to continue their studies in the Bachelor of Nursing Program must submit a written application for reinstatement to the Associate Dean (Undergraduate Programs) by May 1 of each calendar year.
  • The written application must specifically address the academic and non-academic issues that had affected their academic standing prior to their academic suspension and describe how these issues have been addressed and/or resolved. This information should include, at a minimum:
    • An outline of what they have been doing during their time away from Nursing (e.g., developing good study habits, attending counseling, etc.);
    • An explanation of what has changed to make it more likely that they will be successful, and their plan for success if reinstated; and
    • An academic plan for the rest of their program.
• The College of Nursing will consider each request on a case by case basis and reserves the right to deny a student’s request for reinstatement.
• Students who are reinstated or who are actively under consideration for reinstatement will be subject to the following procedures with respect to their course registrations:
  • Students who are suspended at the end of Fall Term (January) will:
    • Request reinstatement by May 1 of the same year in which they were suspended;
    • Be given a final decision by May 15;
    • Register for courses during the College’s registration period; and
    • Proceed to course work in Fall term subject to space availability.
  • Students who are suspended at the end of Winter Term (May) will:
    • Request reinstatement by May 1 of the following year;
    • Be given a provisional decision by May 15;
    • Register for Fall term courses during the College’s registration period; and
    • Proceed to course work in Fall term subject to space availability.
  • Students who are suspended at the end of Summer Term will:
    • Request reinstatement by May 1;
    • Be given a provisional decision by May 15
    • Register for summer term, or the subsequent Fall term, courses during the College’s registration periods; and
    • Proceed to course work in summer term subject to course/space availability.
  • Students who do not apply for reinstatement by this deadline will be considered as having withdrawn from the College of Nursing and will not be permitted to return.
  • Students who are permitted to return from suspension will be required to meet with a Nursing Student Advisor to plan their program.

Required to withdraw

Students who have been permitted to return from Suspension and whose TGPA drops below 2.5 a fourth time will be Required to Withdraw. Students who are Required to Withdraw are ineligible for re-admission to the College of Nursing.

Policy #21	Application for exemption from the clinical education 'Beyond-the-Perimeter' requirement
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline a process and rationale whereby a student may apply for exemption from completing the “Beyond-the-Perimeter” criteria that is expected in their clinical education experience.

To expand exposure to physical therapy services in a variety of geographical settings, students are expected to complete a minimum of one clinical placement outside of Winnipeg. This opportunity adds depth to a student’s clinical education profile and offers experiences not available within the City of Winnipeg. However, in some circumstances this clinical education expectation creates exceptional hardship for students and/or their families.

Policy Statements

21.1 To request exemption from the “Beyond-the-Perimeter” clinical education requirement, students must apply in writing to the Academic Coordinator of Clinical Education. The letter must outline the reasons for the request, and the length of the requested exemption. Students will provide a copy of this request to their Program Advisor and the Head of the Department of Physical Therapy.

21.2 Students can apply for the exemption at any time during the Master of Physical Therapy program, however it will not apply to clinical placements that were posted prior to its submission.

21.3 A committee consisting of the Head, Department of Physical Therapy, the Academic Coordinator of Clinical Education and the student’s Program Advisor and will review the request and make a determination. The student will then be informed.

21.3.1 Honouring this exemption shall not disadvantage another student in the Master of Physical Therapy program. Therefore, it is possible that a student receiving this exemption may be required to defer their clinical placement to the end of the program.

Policy #10	Assignments and projects during clinical placements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline expectations related to assignments and projects during clinical placements.

Policy Statements

10.1 Site Specific Assignments and Projects

10.1.1 Site-specific assignments and special projects may be included as part of the clinical placement experience. These projects should be based on the learning objectives for the clinical placement. University guidelines for assignments and special projects include:

10.1.1.1 Assignment topic and format should be discussed and agreed upon by the Clinical Instructor and the student early in the clinical placement (before midterm).

10.1.1.2 Assignments should be relevant to the current clinical placement.

10.1.1.3 Assignments should be designed to facilitate personal and professional growth of the individual student.

10.1.1.4 Assignments should not duplicate traditional academic course assignments.

10.2 Time requirements for assignments should not prevent the student from participating in activities at the Clinical Education Site. The student may be expected to complete some work related to the assignment outside of work hours. It is expected that the student and their Clinical Instructor will be able to negotiate reasonable expectations re time commitments.

10.3 Library Privileges:

10.3.1 Students who are provided with library privileges at the Clinical Education Site to facilitate the completion of assignments and projects are subject to the rules and regulations of the Clinical Education Site library.

10.3.2 All books and materials must be returned to the library by the end of the clinical placement.

10.3.3 The student is responsible for payment of any fines incurred due to overdue material books that they have borrowed.

10.4 Computer & Internet Access:

10.4.1 Students using computers and/or internet services at the Clinical Education Site to facilitate the completion of assignments and/or projects are subject to the rules and regulations governing the use of computers and internet services at the Clinical Education Site.

 

Policy #14	Cancellation of clinical placements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline the process for cancellation of a clinical placement by the Clinical Education Site or the Academic Coordinator of Clinical Education.

Policy Statements

14.1 Cancelation of a clinical placement:

14.1.1 The Clinical Education Site personnel or the Academic Coordinator of Clinical Education and should attempt to notify each other of a clinical placement change or cancellation as soon as possible.

14.1.2 It is recommended that whenever possible, clinical placement changes or cancellations occur no later than four weeks prior to the beginning of a clinical placement.

14.1.3 In the event of a clinical placement being changed or cancelled, the location and type of the replacement clinical placement may be different from the initially allocated clinical placement.

14.1.4 If a placement is cancelled, the student will be notified by the Academic Coordinator of Clinical Education. Every attempt will be made to find the student an alternate clinical placement in the same time slot, however this may delay the student’s graduation date.

 

Policy #3	Contact with clinical education sites
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline the requirements for students regarding contact with Clinical Instructors prior to the commencement of a clinical placement.

Policy Statements

3.1 All students are required to provide an introductory email to their assigned Clinical Education Site - to their Clinical Instructor(s) where known, and to the site contact if this is a different person. The introductory email will be sent two weeks prior to the clinical placement start date unless otherwise directed by the Academic Coordinator of Clinical Education.

3.2 Students will copy the Administrative Coordinator of Clinical Placements into the introductory email to allow tracking and ensure that all students contact their Clinical Education Sites prior to the clinical placement start date.

3.3 In the introductory email, students will include their contact details, the clinical placement type, start and end dates, and a request for information regarding when and where to meet on the first day, type of caseload to expect and any other site-specific details such as unusual clothing requirements and parking tips that will assist their preparation for the clinical placement.

3.4 Students will attach a current copy of their curriculum vitae to the introductory email, which will include their clinical placement history and any other information they feel is relevant. The curriculum vitae will utilize the template provided in class and will have been reviewed by the student’s Program Advisor.

Policy #9	Clinical education hours
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To provide guidelines as to how clinical placement hours are determined in order that each student shall complete the required minimum 1025 hours of clinical placements.

Policy Statements

9.1 Clinical education hours: The Canadian Alliance of Physiotherapy Regulators and Physiotherapy Education Accreditation Canada require students to successfully complete a minimum of 1025 hours of clinical placements in order to meet requirements for graduation and attempting the written component of the Physiotherapy Competency Exam. The University of Manitoba Master of Physical Therapy program includes 1,088 clinical placement hours (29 full-time weeks x 37.5 hours/week). This represents 63 hours more than the total required, ensuring all students obtain the mandated clinical education time.

9.1.1 It is anticipated that students will need to spend additional hours in preparation, reflection and documentation of their clinical placement practice.

9.1.2 Students' working hours on-site (including lunch, coffee breaks, daily work schedule, etc.) are determined according to the policies/regulations of the Clinical Education Site.

9.1.3 Students may be required to work evenings and weekends in accordance with the requirements of the Clinical Education Site.

9.1.4 Students may accumulate banked time in accordance with Clinical Education Site policies.

9.2 Absenteeism:

9.2.1 Attendance by students in clinical placements is mandatory. If a student will be absent from the clinical placement for any reason, they must notify their Clinical Instructor (or Clinical Education Site Leader if appropriate) and the Academic Coordinator of Clinical Education as soon as possible, and preferably prior to the absence. Approval for student non-attendance is jointly made by the Clinical Instructor (or Clinical Education Site Leader, if appropriate) and the Academic Coordinator of Clinical Education. Possible acceptable reasons for absence may include personal illness/injury, illness or death of a family member, appointments, religious holidays, University committee work, and activities relating to provincial/national/international representation.

9.2.2 Illness/injury: If a student is absent for three or more consecutive days because of illness, they may be required to submit a certificate from a licensed physician/dentist to their Clinical Instructor upon their return to the Clinical Education Site, with a copy forwarded to the Academic Coordinator of Clinical Education. The student should consult with the Clinical Instructor and the Academic Coordinator of Clinical Education to determine if this will be required.

9.2.3 Compassionate reasons: If a student is absent for compassionate reasons, Clinical Instructor and the Academic Coordinator of Clinical Education should be informed. If the allowed number of days of absence from the clinical placement is exceeded, then policy 9.3relating to making up time applies.

9.2.4 Religious holidays: If a student intends observing a religious holiday other than those specified as statutory holidays, they must inform their Clinical Instructor and the Academic Coordinator of Clinical Education before the beginning of the clinical placement. If the allowed number of days of absence from the clinical placement are exceeded, then the policy relating to making up time applies.

9.2.5 University/professional committee work: A student representing physical therapy as a member of a University committee or a professional organization will not be required to make up time for absence from the clinical placement incurred by one of these meetings. The student is responsible for informing their Clinical Instructor and the Academic Coordinator of Clinical Education as soon as possible of the dates of meetings (in advance when possible).

9.2.6 Provincial/national/international representation: A student who is involved in sports, arts or other activities at a provincial, national or international level and is required to participate/compete in an associated event during their clinical placement, should inform the Academic Coordinator of Clinical Education as soon as possible of the dates of the activities/competition. If the allowed number of days are exceeded, then policy 9.3 relating to making up time applies, or the student may request that they be allowed to complete the clinical placement at a time that does not interfere with any scheduled activities/competitions.

9.2.7 Educational events: Requests for time away from the Clinical Education Site to attend conferences, workshops, or other educational activities not directly related to the clinical placement may be considered. The student and should consult with the Clinical Instructor and the Academic Coordinator of Clinical Education who will consider the request and make recommendations about the suitability of the activity.

9.2.8 Appointments: Students should endeavor to arrange all appointments outside of clinical placement hours. All non-emergency doctor/dentist appointments should be arranged to avoid conflicting with clinical placements. If a student is required to attend an emergency appointment, notice should be given as soon as possible to the Clinical Instructor and the Academic Coordinator of Clinical Education.

9.2.9 Personal Needs: It is expected that students will not ask for shortened workdays to accommodate personal needs and/or job commitments.

9.3 Make-up time:

9.3.1 In general, a student should endeavour to ‘make-up’ all time missed from clinical placements. It is preferable if make-up time can be accommodated within the current clinical placement by working additional hours, evenings, or weekends. Make-up hours should be compatible with the focus of the program and if possible, allow contact with clients and the continual development of knowledge and skills. Make-up time should not be designed to simply ensure the student fulfills a minimum hourly requirement but should fit with the clinical education objectives.

9.3.2 If a student has not been able to schedule make-up time within the current clinical placement (i.e. if additional time cannot be accommodated due to the nature of the Clinical Education Site/program and/or if absences occur toward the end of a clinical placement), a student may be required to make-up time missed from clinical placements if the total days absent from the regularly scheduled clinical placement time exceeds two days. This decision is made by the Clinical Instructor and Academic Coordinator of Clinical Education and is informed by the student’s achievement of the clinical placement objectives.

Policy #1	Clinical education policies – general information
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To serve as a guide for faculty, site leaders, Clinical Instructors, and students during clinical placements.

1.1 The Master of Physical Therapy Program Clinical Education Policies will be posted on the College of Rehabilitation Sciences web site.

1.2 Students must comply with the policies and procedures of the particular Clinical Education Site at which they are completing their clinical placements.

1.3 The Master of Physical Therapy Program Clinical Education Policies should be used as adjunct guidelines in consideration of existing Clinical Education Site policies and procedures.

1.4 In the event of a conflict between the Clinical Education Site policies and procedures and the Master of Physical Therapy Program Clinical Education Policies, the Academic Coordinator of Clinical Education should be informed as soon as possible.

Policy #20	Clinical education site approval
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline requirements for approval of Clinical Education Sites providing clinical placement opportunities for students in the Master of Physical Therapy program.

Policy Statements

20.1 Each site is required to submit a National Association of Clinical Education Professional Practice Site Profile Form, to be completed by the appropriate individual at the site. These forms will be implemented when sites are approved, and every five years thereafter.

20.1.1 Professional Practice Site Profile Information: Site Contact Information, Type of Facility, Insurance Information, Facility Ownership, Continuing Professional Education Access, Type of Charting, Dress Code, Parking, Accommodation, Staffing, Requirements for Criminal Record and other Checks/Mask Fit testing/Immunizations, Other Health Professionals On-site, Diagnostic Categories of Patients, Special Programs, Clinics, Student Learning Opportunities in terms of CVP/Ortho/Neuro/Specialities/Other.

20.2 In some situations, based on sufficient information, sites may provide a clinical education opportunity for a student prior to all documentation being completed. In this situation the Academic Coordinator of Clinical Education or designate may conditionally approve the site for use.

20.3 Sites approved by other university programs will be considered approved.

Policy #15	Clinical placement grades
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline the decision process for assigning a pass or fail in a clinical placement and procedures related to failure of a clinical placement/course.

Policy statements

15.1 It is the responsibility of the Clinical Instructor to assign the final grade for the clinical placement on the Assessment of Clinical Practice form on HSPnet.

15.2 The Clinical Instructor must inform the Academic Coordinator of Clinical Education as soon as possible regarding any student performance issues that put the student at risk of failure, to enable the development of a robust remediation process to directly address the student’s identified deficiencies.

15.3 Failure of a clinical placement:

15.3.1 A Clinical Instructor will not assign a student a failing grade for a clinical placement without prior, direct involvement of the Academic Coordinator of Clinical Education.

15.3.2 Students may be permitted to repeat one failed clinical placement over the duration of the program.

15.3.3 A student receiving a fail in a clinical placement must successfully repeat that clinical placement prior to progressing to the next clinical education course.

15.3.4 Students who fail more than one clinical placement will be required to withdraw from the program.

Note: Because clinical education courses are closely juxtaposed with academic components, students may proceed into clinical placement without having received official final grades in preceding academic course work.

Policy #6	Clinical placements within Manitoba - arrangements for accommodation, transportation, and food
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To describe the process and resources available to University of Manitoba students participating in clinical placements within Manitoba.

Policy Statements

6.1 Students are responsible for all costs related to clinical placements within the Winnipeg perimeter, including transportation costs.

6.2 Each student should be prepared to complete a minimum of one clinical placement beyond the Winnipeg perimeter.

6.2.1 To prevent undue financial hardship, students receiving a clinical placement outside Winnipeg but within Manitoba will receive support for some transportation and accommodation costs.

6.2.2 Students must consult with the Academic Coordinator of Clinical Education prior to the beginning of the clinical placement to determine if and how the reimbursement policies apply to their specific situation.

6.2.3 The Administrative Coordinator of Clinical Placements will make accommodation arrangements for students who are placed outside of Winnipeg for clinical placements. Once a student has confirmed in writing that they do or do not require accommodation, no changes are allowed.

6.2.4 If a student chooses to arrange their own accommodation, they must inform the Administrative Coordinator of Clinical Placements as soon as possible. In such cases, the student must have the cost of accommodation pre-approved by the Academic Coordinator of Clinical Education or the Administrative Coordinator of Clinical Placements or they will not be reimbursed. Generally, students will not be reimbursed for accommodations costs that exceed those that can be arranged by the University.

6.2.5 If the University has arranged a place of accommodation and the student decides to move from this place of accommodation, they must inform the Academic Coordinator of Clinical Education before initiating the move. The Academic Coordinator of Clinical Education will determine if the change will be approved and paid for, given the specific circumstances.

6.2.6 In situations where the student is on clinical placement outside of Winnipeg and the student chooses to stay with family or friends and commute to the Clinical Education Site rather than stay at accommodation arranged by the University closer to the clinical placement site, the student must choose to either be reimbursed for transportation costs OR to have accommodation provided/paid for by the University.

6.2.7 To be reimbursed for expenses incurred during the clinical placement, students must submit original receipts for expenses along with the completed Travel Reimbursement Form to the Administrative Coordinator of Clinical Placements.

6.3 Students allocated to Clinical Education Sites beyond the perimeter will be reimbursed for transportation expenses as follows:

6.3.1 Transportation expenses reimbursed will be to an amount equal to, or less than, the cost of one round-trip bus fare between Winnipeg and the Clinical Education Site (as outlined below). There is no reimbursement for travel to and from the Clinical Education Site regardless of location.

6.3.2 If a student chooses to travel by car, the student will be reimbursed for actual gas costs unless such costs are greater than the cost of one round trip bus fare (which is the maximum allowable amount).

6.3.3 If two or more students travel together by car to and from the Clinical Education Site, only the equivalent of one student’s round-trip bus fare will be reimbursed.

6.3.4 If a student chooses to commute by car to and from a Clinical Education Site beyond the Winnipeg perimeter (e.g. Steinbach, Portage La Prairie, Beausejour or Selkirk) OR wishes to reside at a family/friend’s home and commute to a Clinical Education Site in a rural location rather than stay at accommodation close to the Clinical Education Site, then the student will be reimbursed for transportation costs. These will be based on original gas receipts up to and not exceeding $12/day of attendance at the clinical placement. Students are required to complete the “Form to Complete for Commuting” available on the clinical education course page of the University web-based educational platform or from the Administrative Coordinator of Clinical Placements.

6.3.5 Students are strongly discouraged from commuting to Clinical Education Sites beyond a 75-kilometre radius of their place of lodging.

6.3.6 In situations where the student is on clinical placement outside of Winnipeg and is required to use their car to participate in, or complete certain aspects of the clinical placement, and the Clinical Education Site is unable to provide financial support for transportation, the student should consult with the Academic Coordinator of Clinical Education to determine if the costs of transportation are eligible for reimbursement. If the Academic Coordinator of Clinical Education determines that the travel is essential, the student may be reimbursed on a per kilometre basis consistent with University of Manitoba staff policy. This amount will not exceed $50.00 per clinical placement. Note: Students are advised not to transport clients in their car unless they have obtained appropriate insurance coverage.

6.3.7 If a student is placed with the J.A. Hildes Northern Medical Unit, the Unit will pay the costs for return airfare to and from Rankin Inlet, Nunavut and the cost of one return airfare to and from a remote community serviced by the Physical Therapist (dependent on yearly negotiations).

6.4 Accommodation expenses allotted will be to an amount less than or equal to the cost of accommodations arranged by the University.

6.4.1 If there is a cost for accommodation, the individual providing lodging must submit a written invoice to the University of Manitoba c/o the Administrative Coordinator of Clinical Placements indicating the dates and cost of accommodation.

6.4.2 Invoices should be submitted as soon as possible and no later than 6 weeks after completion of the clinical placement. Invoices received after this date will not be processed.

6.4.3 Wherever possible, attempts will be made to have direct billing to the University to avoid the need for students to be reimbursed.

6.4.4 Students are responsible for payment of refundable damage deposits. Students are also responsible for payment of any damages to the place of accommodation that occur during their stay.

6.4.5 If a student is invited to travel with their Clinical Instructor during a clinical placement, and the trip will involve an overnight stay(s), the student or clinical instructor should consult with the Academic Coordinator of Clinical Education to determine if support is available to assist with the costs of accommodation.

6.5 Food costs will not be reimbursed:

6.5.1 If the cost of accommodation also includes food, and the cost of food is not specified, the student will be responsible to pay a predetermined amount per day in food costs.

6.5.2 Depending on the situation, the student may have to pay for food costs in an advance lump sum at the beginning of the clinical placement/accommodation period. It is the student’s responsibility to ensure this fee is paid. Students for whom this will cause financial or other difficulty must inform the Academic Coordinator of Clinical Education immediately, so that arrangements for alternate accommodation can be made where possible.

6.6 Clinical Education Sites with no pre-established legal agreement or affiliation with the University of Manitoba:

6.6.1 If a student wishes to complete a clinical placement at a site that does not have a pre- established affiliation or legal agreement with the University of Manitoba, the student should arrange to meet and discuss the matter with the Academic Coordinator of Clinical Education.

6.6.2 Requests for new Clinical Education Sites must be made a minimum of 6-8 months in advance of the anticipated clinical placement dates.

6.6.3 The learning objectives and location of any clinical placement must meet the approval of the Department of Physical Therapy and the University of Manitoba.

6.6.4 A student who requests a clinical placement at a specific site that does not have a pre-existing legal agreement and affiliation with the University of Manitoba should be aware that a Clinical Education Site usually requires a contractual (legal) arrangement with the University of Manitoba prior to the student being permitted to commence their clinical placement. There is no guarantee that the University of Manitoba will be successful in establishing such a contractual arrangement with the new site, in which case the student should be prepared to select an alternate Clinical Education Site.

Policy #7	Clinical placements outside of Manitoba but within Canada – arrangements for accommodation, transportation, and food
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To describe the process and resources available to students participating in clinical placements outside of Manitoba but within Canada.

Policy Statements

7.1 Students may complete clinical placements outside of Manitoba, however their first placement in first year must be located in Manitoba.

7.2 There is no reimbursement of any costs related to clinical placements outside Manitoba (with the exception of the Nunavut placement sponsored by Ongomiizwin Health Services).

7.3 Students may submit applications to the Academic Coordinator of Clinical Education for clinical placements outside of the University of Manitoba’s provincial catchment area. Upon approval of the application, the Academic Coordinator of Clinical Education will forward it to the appropriate university physical therapy educational program.

7.4 If a student wishes to access out-of-catchment clinical placements, they will be responsible to pay the associated application fee. The student must provide a cheque payable to the University of Manitoba at the time of submission of the clinical placement request form. If the cheque is returned by the bank for non-sufficient funds, the student will be charged the appropriate non-sufficient fund fee, in addition to the clinical placement fee.

7.5 Students will follow the procedure for applying for the out-of-catchment clinical placement.

7.6 Any additional costs incurred/ levied by a Clinical Education Site outside of the University of Manitoba’s catchment area (e.g. administrative fee) will be the student’s responsibility.

7.7 Sites with no pre-established legal agreement or affiliation with the University of Manitoba:

7.7.1 If a student wishes to complete a clinical placement at a site that does not have a pre-established affiliation or legal agreement with the University of Manitoba, the student should arrange to meet and discuss the matter with the Academic Coordinator of Clinical Education.

7.7.2 Requests for new Clinical Education Sites must be made a minimum of 6–8 months in advance of the anticipated clinical placement dates.

7.7.3 The learning objectives and location of any clinical placement must meet the approval of the Department of Physical Therapy and the University of Manitoba.

7.7.4 A student who requests a clinical placement at a specific site that does not have a pre-existing legal agreement and affiliation with the University of Manitoba should be aware that a Clinical Education Site usually requires a contractual (legal) arrangement with the University of Manitoba prior to the student being permitted to commence their clinical placement. There is no guarantee that the University of Manitoba will be successful in establishing such a contractual arrangement with the new site, in which case the student should be prepared to select an alternate Clinical Education Site.

Policy #18	Deferral of clinical placements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To provide guidelines as to how requests for changes to Clinical education dates/times will be addressed.

Policy Statements

18.1 Any requests for postponed/deferred clinical education time must be presented in writing to the Academic Coordinator of Clinical Education at least 6 weeks in advance of the scheduled start date of the clinical placement. The request will only be considered for extenuating circumstances which do not include job commitments or personal travel plans.

Policy #16	Delays or disruptions in clinical placements due to extraordinary circumstances
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To provide guidance regarding steps to be taken in the event of delays or disruptions in a clinical placement due to extraordinary circumstances (e.g. job action, infectious disease, natural disaster).

Policy Statements

16.1 The Clinical Education Site’s policy will guide the University’s decision in dealing with delays or disruptions due to extraordinary circumstances.

16.2 In the event of an extraordinary circumstance, students are to contact the Academic Coordinator of Clinical Education at the first sign of clinical placement disruption.

16.3 Where possible, clinical placements that are disrupted or delayed due to extraordinary circumstances will be accommodated for on a case-by-case basis.

16.3.1 The make-up hour’s policy (9.3) will be used to help guide decisions.

16.3.2 The Academic Coordinator of Clinical Education will discuss with the Clinical Instructor and/or Clinical Education Site Leader the options that are available both prior to, and during any extraordinary circumstance.

16.4 Possible Options:

16.4.1 The Academic Coordinator of Clinical Education will discuss with the Clinical Instructor the possibility of having the student resume the clinical placement after the delay or disruption ends.

16.4.2 Students may be permitted to work on approved projects relevant to the clinical placement, resources permitting.

16.4.3 The Academic Coordinator of Clinical Education will provide an alternate clinical placement at a later date. Every effort will be made to provide a clinical placement prior to the student’s anticipated date of graduation.

Policy #11	Evaluation of student performance on clinical placement
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline evaluation processes involved in the clinical education program.

Policy Statements

11.1 Evaluation of student:

11.1.1 During the first few days of the clinical placement, the student should collaborate with their Clinical Instructor to discuss their learning objectives for the clinical placement and complete the Clinical Learning Contract. The student and their Clinical Instructor should review progress in meeting the objectives at the midterm and final.

11.1.2 The student should continually update their Clinical Skills Checklist during the clinical placement to ensure they have an accurate record of the skills they have observed and practiced. This list should be reviewed at the midterm and final to inform discussion regarding the student’s progress in meeting objectives and will also be used by the program to monitor relevance of teaching content.

11.1.3 Student evaluation is completed by the Clinical Instructor using the Canadian Physiotherapy Assessment of Clinical Practice instrument (ACP) on HSPnet at midterm and final. The student also completes self-reflection regarding their performance using their own copy of the ACP on HSPnet at midterm and final. HSPnet enables the student and Clinical instructor to view both documents simultaneously at midterm and final, which facilitates discussion of perceptions and achievement of performance objectives.

11.1.4 It is recommended that Clinical Instructors enter specific feedback in each comment box of the ACP, indicating areas of strength and areas requiring improvement.

11.1.5 Any areas of concern should be clearly documented in the ACP and discussed with the student to determine a specific plan for the student to improve their performance.

11.1.6 The Academic Coordinator of Clinical Education should be informed by midterm at the latest if there are any concerns about student performance. The Academic Coordinator of Clinical Education is available and ready to assist in the development of the plan to facilitate improvement of the student’s performance.

11.1.7 Students are requested to contact the Academic Coordinator of Clinical Education as soon as possible if they have concerns regarding any aspect of the clinical placement, including issues with their own performance, their clinical instructor, other staff and clients.

11.1.8 The ACP is a University course evaluation document and its content is personal and hence confidential. The Clinical Education Site should not retain a copy of the completed document. It is the student’s decision and responsibility to provide a copy of the ACP to a potential reference.

11.1.9 The student should forward their completed Clinical Learning Contract, and Clinical Skills Checklist to the program upon completion of the clinical placement.

11.2 Evaluation of site:

11.2.1 Students evaluate their experience of the Clinical Education Site using the Student Evaluation of the Clinical Placement form on HSPnet.

11.2.2 The student should complete this form prior to midterm and final and discuss their feedback with their Clinical Instructor at that time.

11.2.3 Clinical education sites may make and keep a copy of this evaluation for their records.

Policy #4	Insurance coverage
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline the liability and other insurance coverage that is in place to cover clinical education activities.

Policy Statements

4.1 Students engaged in a clinical placement as a required part of their program are covered for liability under the University of Manitoba’s General Liability Insurance with the Canadian Universities Reciprocal Insurance Exchange (CURIE). Written documentation relating to the liability coverage is available in the form of a memo from the University of Manitoba administration.

4.1.1 Procedure: Anyone requiring a copy of this memo should contact the Academic Coordinator of Clinical Education.

4.2 Students engaged in a clinical placement in Manitoba as a required part of their program are covered for injuries sustained in the course of and arising out of the clinical placement under the Workers Compensation Act (Manitoba), in accordance with and subject to its provisions.

4.2.1 Procedure: In the event of a student being injured during a clinical placement, the Clinical Instructor or Clinical Education Site Leader should complete any necessary incident reports and promptly contact the Academic Coordinator of Clinical Education to ensure that coverage under the Workers Compensation Act is secured.

4.3 Students in the University of Manitoba Master of Physical Therapy program who are not Manitoba residents who engage in a clinical placement outside Manitoba may not be covered by the Workers Compensation Act (Manitoba). In this event, these students will be covered by an alternative policy through the University of Manitoba.

4.3.1 Procedure: On an annual basis, the Administrative Coordinator of Clinical Placements will inform the University of Manitoba Risk Management & Security Services of the number of non-Manitoban students who completed clinical placements outside of Manitoba during the last year.

4.4 International students in the University of Manitoba Master of Physical Therapy program who are attempting to arrange a clinical placement in their own country-of-origin may experience difficulties or be denied the clinical placement because the University is not able to guarantee that they will have workers compensation coverage during the clinical placement. Alternative arrangements can sometimes be made to cover these clinical placements, but this is done on a case-by-case basis. Students are encouraged to contact the Academic Coordinator of Clinical Education at the earliest opportunity to determine if any such alternative arrangements are possible.

 

 

Policy #8	International clinical placements
Approved by	Clinical Education Committee
Approval date	December 21, 2022

Purpose: To describe the process and resources available to students participating in international clinical placements.

Policy Statements

8.1 International clinical placements are opportunities which may be made available to students who have demonstrated excellence in their academic and clinical education work, a high level of self-directed learning and a history of embracing new opportunities within the Master of Physical Therapy program. International clinical placements can either be initiated by the student or may be facilitated by the Department of Physical Therapy (e.g. exchange programs, established Clinical Education Sites). There is no reimbursement of any costs related to clinical placements outside of Manitoba.

8.2 To be considered for this opportunity, students must:

8.2.1 Maintain a B+ average in their academic courses within the Master of Physical Therapy program.

8.2.2 Demonstrate excellence in clinical education as evidenced by their clinical education evaluations.

8.3 Students are not permitted to participate in international clinical placements in the first year of the program.

8.4 Students are required to initiate their request to complete an international clinical placement by approaching the Academic Coordinator of Clinical Education at least one year in advance.

8.5 Permission is given jointly by the Head of the Department of Physical Therapy, the Academic Coordinator of Clinical Education and the student’s Program Advisor. Permission is conditional upon the student maintaining the required level of academic and clinical education performance. Failure to do so will result in the student losing the opportunity to participate in the international clinical placement.

8.6 There is no reimbursement of any costs related to international clinical placements. Students must assume responsibility for all costs including:

8.6.1 Medical coverage

8.6.2 Visas

8.6.3 Accommodation

8.6.4 Travel

8.6.5 Any travel related vaccinations

8.6.6 Any additional required insurance coverage that is not routinely provided by the University

8.6.7 Phone calls, faxes, and postage to the Clinical Education Site.

8.7 For student-initiated clinical placements, students are responsible for checking in with the University’s International Centre via the Travel Tools page to identify potential travel restrictions before proceeding to make preliminary contact with prospective Clinical Education Sites to obtain written documentation as follows:

8.7.1 Description of the physical therapy service/program

8.7.2 Student Learning objectives

8.7.3 Evidence of professional organization accreditation or university approved status/affiliation.

8.8 The student must contact the local licensing body to determine if student licensure is required and the process involved.

8.9 The student must provide the Academic Coordinator of Clinical Education with copies of all correspondence between the student and the prospective Clinical Education Site.

8.10 The student must commit to the clinical placement once approval has been granted by the Master of Physical Therapy program.

8.11 A student who requests a clinical placement at a specific site that does not have a pre-existing legal agreement and affiliation with the University of Manitoba should be aware that a Clinical Education Site usually requires a contractual (legal) arrangement with the University of Manitoba prior to the student being permitted to commence their clinical placement. There is no guarantee that the University of Manitoba will be successful in establishing such a contractual arrangement with the new site, in which case the student should be prepared to select an alternate Clinical Education Site.

8.12 Students participating in international clinical placements must complete the following items on the University of Manitoba’s Travel Tools page :

8.12.1 The International travel registry at least 2 weeks prior to departure.

8.12.2 The pre-departure preparation courses provided on UMLearn (proof of completion to be sent to the Academic Coordinator of Clinical Education.

8.12.3 Sign and submit Informed Consent document, which is an Acknowledgement of Responsibility and Liability Waiver. This form outlines assumption of risk, assumption of responsibility and a liability while participating in international clinical placements.

8.12.4 Complete an emergency contact and medical information form prior to departure. This form will be kept on file in the office of the ACCE in case of an emergency during the clinical placement. At the end of the clinical placement, the form will be shredded. 

Policy #19	Primary clinical instructor qualifications
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To provide guidelines regarding qualifications required of primary Clinical Instructors for students in the University of Manitoba Master of Physical Therapy program.

Policy Statements

19.1 Primary clinical Instructors must be registered with their provincial (or relevant) regulatory body.

19.2 Completion of a Clinical Instructor Workshop is preferred but not required.

19.3 Completion of Clinical Instructor online training through the Universities of British Columbia or Western Ontario is preferred but not required.

19.4 Completion of a minimum of one year of post-licensure clinical experience.

19.4.1 Individuals with less than one full year of practice who have full registration with their regulatory college (i.e. who have passed the practical component of the Physiotherapy Competency Exam) may serve as primary clinical Instructors under the supervision of a more experienced Clinical Instructor. In this situation, the novice Clinical Instructor may contribute to the student evaluation, but the experienced Clinical Instructor will assume ultimate responsibility for guiding and evaluating the student on the clinical placement.

19.5 Physiotherapists who are currently under investigation, practice restriction or censure by the College of Physiotherapists of Manitoba must not supervise students on clinical placement for the duration of the investigation, practice restriction or censure. The College of Physiotherapists of Manitoba will inform the physiotherapist of this requirement at the commencement of the investigation, practice restriction or censure. Physiotherapists from other jurisdictions who are currently under investigation, practice restriction or censure by their regulatory college must not supervise students from the University of Manitoba program.

Policy #12	Professional appearance
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline expectations regarding professional appearance during clinical education activities which are considered appropriate according to current health care standards.

Policy Statements

12.1 Guidelines

12.1.1 Dress code requirements may vary from site to site. Students must comply with the dress code of the particular Clinical Education Site at which they are completing their clinical placements. The following guidelines are based on the WRHA Dress Code Policy (#20.10.020) and serve as a general guide.

12.1.2 Clothing

12.1.2.1 Clothing and accessories should be clean, neat and of appropriate length, design, and fabric, and should not reveal underwear or the skin of the trunk, including with more active postures associated with therapeutic interventions.

12.1.2.2 “Business casual” attire is the generally accepted style for clinical placements unless otherwise directed by the Clinical Education Site. Jeans, shorts and risqué outfits are not considered appropriate apparel.

12.1.2.3 Clothing shall not display offensive language, logos, or images.

12.1.3 Footwear

12.1.3.1 Footwear should be clean, meet safety requirements of the work area and provide for safe mobility.

12.1.4 Jewellery

12.1.4.1 Jewelry should not interfere with the practice of routine precautions or present surfaces that could result in injury to client or self.

12.1.5 Personal Hygiene

12.1.5.1 Good personal hygiene and cleanliness shall be practiced.

12.1.5.2 Hair should be clean and not able to fall where it may contact clients and other surfaces.

12.1.5.3 Nails should be clean and short. Artificial fingernails, gel nails, or extenders shall not be worn.

12.1.6 Scented Products

12.1.6.1 Fragrances and other scented products should not be used/worn by students on clinical placement.

12.1.7 Headphones

12.1.7.1 The wearing of headphones/ear plugs in conjunction with personal electronic devices is not permitted during clinical placement hours.

12.1.8 Nametags

12.1.8.1 University of Manitoba nametags must be worn at all times during clinical placements.

12.1.8.2 One nametag is ordered for each student at the beginning of the Master of Physical Therapy program. If a student loses their nametag, they should inform the Academic Coordinator of Clinical Education immediately so that a replacement nametag can be ordered. Students are responsible for the cost of their initial nametag and any replacements.

12.1.8.3 Students may also be supplied with an identification badge by their Clinical Education Site. Students are expected to also wear this badge in compliance with the policies of the Clinical Education Site. These nametags must be returned to the Clinical Education Site at the end of the clinical placement.

Policy #13	Professional behaviour
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline expectations relating to professional behavior during clinical placements.

Policy Statements

13.1 Ethics:

13.1.1 Each student should review and adhere to the Codes of Ethics of the College of Physiotherapists of Manitoba, Canadian Physiotherapy Association and the University of Manitoba during clinical placements.

13.1.2 Students on clinical placement outside Manitoba should review and adhere to the appropriate provincial/national code of ethics that pertains to the geographic area in which they are situated.

13.1.3 Students are expected to follow the policies and procedures of their Clinical Education Site for the period of the clinical placement.

13.1.4 Clinical Education Site policies concerning the acceptance of gifts from clients will apply to students completing clinical placements at the site.

13.2 Title:

13.2.1 Students must only use the title "Student Physical Therapist" or “Student Physiotherapist" to clearly identify their student status. This title is to be used on a nametag, in documentation, on written projects, etc.

13.3 Professional Behaviour:

13.3.1 Students are expected to comply with any provincial legislation which directs professional behaviour (e.g. Mental Health Act, Protection of Persons in Care Act, Vulnerable Persons Act, etc.)

13.4 Representation:

13.4.1 Students are considered representatives of the physical therapy profession and the University of Manitoba and should behave accordingly.

13.5 Confidentiality:

13.5.1 It is essential that students maintain confidentiality in all matters related to clients. This is important both in oral communication with/about clients and in the handling of written communication such as charts.

13.5.2 Students are legally responsible to follow any provincial legislation that pertains to confidentiality of clients (e.g. the Personal Health Information Act [PHIA]). Students who are completing clinical placements in other provinces or countries are responsible for determining the name and specific requirements of the appropriate local legislation and adhering to the law.

13.6 Documentation:

13.6.1 Documentation or notes which are written by students should be signed by the student in the following manner: Student Name (Student Physical Therapist or Student Physiotherapist).

13.6.2 Students are required to familiarize themselves with the charting/documentation requirements of their Clinical Education Site and to adhere to those policies and/or guidelines.

13.6.3 Some Clinical Education Sites may require a student to attend a documentation training session prior to their clinical placement. Students are expected to arrange to attend this scheduled orientation.

Bylaw name	Professional unsuitability
Effective date	September 1, 2021
Scheduled review date	10 years from Effective Date
Approving body	University Senate
Authority	The University of Manitoba Act
Responsible executive officer	Executive Officer: President
Contact	Department head, Department of Occupational Therapy, College of Rehabilitation Sciences
Delegate	Dean, Faculty of Graduate Studies
Application	Students in the Master of Occupational Therapy Program

Preamble

The Faculty of Graduate Studies at the University of Manitoba has established a Master of Occupational Therapy Program (the “Program”) administered by the Department of Occupational Therapy within the College of Rehabilitation Sciences, Rady Faculty of Health Sciences. The purpose of this Master of Occupational Therapy Program Bylaw is to set out the authority of the Program’s Professional Unsuitability Committee (“PUC”) and to set out its procedures for professional unsuitability hearings.

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1.0 Reason for Bylaw

1.1 The Program has a social mandate to ensure that students become caring, skilled occupational therapists who are competent to practice. In fulfilling this mandate, the  Department of Occupational Therapy has developed a comprehensive program of academic  and fieldwork courses to ensure that graduates meet these expectations. The Program  requires students to uphold the high standards of professional practice expected of all  occupational therapists in action, word, intent, and spirit. The Program also has the obligation  to maintain the safety of students, colleagues, faculty and clients with whom its students have contact.

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2.0 Rule/Principle

2.1 As members of the University community, students are obligated to act with integrity and diligence in carrying out their professional responsibilities, and their behaviour and conduct in relation to others ought to be characterized by consideration, respect, and integrity. 

2.2 Grounds under which a student may be reviewed under this Professional Unsuitability Bylaw include, but are not limited to, instances where the student:

a) engaged in behaviour or conduct that if engaged in by a practicing registered occupational therapist could result in suspension, expulsion or other serious disciplinary action by the regulatory body of the profession for occupational therapy;

b) jeopardized client-centred care through self-interest or a conflict of interest;

c) demonstrated unsafe practice or poor professional judgment in any clinical setting which resulted or could have resulted in harm to others;

d) demonstrated behaviour with respect to other students, colleagues, faculty or the public which is exploitive, irresponsible or destructive;

e) acquired, while in the Program, a criminal conviction which according to the Program was determined to be of such a nature as to bring disrepute to the profession, or by which in the opinion of the Program, the student demonstrated poor judgment, lack of integrity or other unsuitability for the profession; 2 January 30, 2020

f) has been placed on the Child Abuse Registry and/or Adult Abuse Registry in any jurisdiction while in the Program;

g) exhibited a health condition, the occurrence of which impairs essential performance required for the occupational therapy profession, recognizing that reasonable accommodation of the special needs of students is required by the Manitoba Human Rights Code;

h) practiced or provided client care while impaired, including being under the influence of alcohol or drugs while participating in client care, a professional activity, or any activity related to the practice of the occupational therapy profession;

i) demonstrated behaviour that violated the Code of Ethics of the College of Occupational Therapists of Manitoba. 

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3.0 Jurisdiction and Authority

3.1 This By-Law applies to students enrolled in the Master of Occupational Therapy Program in the Department of Occupational Therapy, College of Rehabilitation Sciences and has been developed under the authority granted to the Program by the Faculty of Graduate Studies.

3.2 The Program may require a student to withdraw from all Program courses pursuant to the procedures set out in this By-Law if the student has been found unsuited, on consideration of competence, conduct or professional fitness, for the practice of occupational therapy. Upon a finding of professional unsuitability, the Program may require a student to withdraw from Program courses at any time throughout the academic year or following the results of examinations at the end of any academic term. The Program’s right to require withdrawal prevails notwithstanding any other provision in the Program's Rules or Regulations. The Code of Ethics of the College of Occupational Therapists of Manitoba, as the ethical basis for occupational therapy in Manitoba, will be considered in every situation in which an inquiry is being held pursuant to this By-law into the conduct of a student in the practice of occupational therapy.

3.3 Conflict of Jurisdiction: If a question arises as to whether a matter falls within the academic regulations of the Department or this By-Law, or as to whether a matter is within the jurisdiction of the Student Discipline By-Law of the University or this By-Law, as the case may be, the question shall be referred to the President of the University (or delegate) for final decision. 

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4.0 Professional Unsuitability Committee (PUC)

4.1 There shall be established within the Department of Occupational Therapy a standing committee known as the Professional Unsuitability Committee (PUC) to hear and determine matters of competence or professional suitability for Program students with respect to professional conduct and practice.

4.2 Membership in the PUC shall be as follows:

a) Chair (non-voting, except in the case of tie): tenured faculty member or instructor in a continuing appointment to be appointed by the Head, Department of Occupational Therapy for a five (5) year term, which may be renewable.

b) two (2) registered occupational therapists who are academic members of the Program, elected by the Occupational Therapy Departmental Council, for a five (5) year term, which may be renewable;

c) one (1) student from the Program, preferably from Year 2; appointed by the College of Rehabilitation Sciences Students’ Association for a one (1) year term, which may be renewable if the student is from Year 1 of the program; and 3 January 30, 2020

d) one (1) representative from the College of Occupational Therapists of Manitoba appointed for a two (2) year term, which may be renewable.

4.3 A quorum of the PUC shall be four (4) members, comprised of the Chair and three (3) members of the Committee, as set out in section 4.2. The Chair will endeavour to arrange meetings in a manner that facilitates the attendance of representatives from all constituencies.

4.4 In the event of a perceived conflict of interest, replacement Committee Members will be appointed/elected by the appropriate constituencies, as defined in 4.2. 

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5.0 Referral

5.1 Anyone affiliated with the Department of Occupational Therapy or associated fieldwork sites and/or institutions, who has a concern about the professional conduct of any student from the Program, shall complete the Professional Unsuitability Referral Form (see attached) documenting the alleged incident(s). The form shall be submitted to the Head, Department of Occupational Therapy who will review with the Academic Fieldwork Coordinator or designate and, if the matter is deemed appropriate, will refer it to the Dean of the Faculty of Graduate Studies (or designate).

5.2 In no circumstances will a referral related to this Bylaw involving a Program student be based on anonymous allegations or materials. The Department Head may, however, inquire or investigate into matters raised by anonymous material. Anonymous materials are defined as “materials in which the authorship has not been disclosed to the student and the PUC.”

5.3 If, in the opinion of the Dean of the Faculty of Graduate Studies (or designate), the matter involves conduct or circumstances as defined in 2.2 and 3.2 herein, the matter, including all supporting documentation, shall be referred to the Chair of the PUC within five (5) working days.

5.4 On receipt of a referral from the Dean of the Faculty of Graduate Studies (or designate), the PUC shall:

a) consider whether just cause exists to suspend the student while the matter is being determined and if so, to issue an interim suspension to the student;

b) send a Notice of Hearing with a copy of the submitted Professional Unsuitability Referral Form, the attached report signed by the individual who has filed the complaint, and any commentary from the Dean or Department Head to the student named pursuant to Article 6.1;

c) at all times act expeditiously to complete the hearing;

d) determine whether any of the grounds requiring withdrawal under Article 2.2 and 3.2 exist after hearing the matter pursuant to this Bylaw; and

e) make a disposition in accordance with Article 8.0 herein.

5.5 Once a referral has been made to the PUC, its proceedings may continue notwithstanding that the student has subsequently voluntarily withdrawn from the program or has refused to participate in the proceedings.

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6.0 Notice and Due Process

6.1 Within ten (10) working days after receipt of the referral, the Chair of the PUC shall inform the student in writing of the grounds for referral to the PUC, as well as the membership of the PUC and the date, time, and place for the hearing by the PUC of the matters set out in the referral. Students should be notified of the opportunity to seek advice and representation from Student Advocacy or the University of Manitoba Graduate Student Association (“GSA”). Such a hearing will be held no sooner than ten (10) working days from the date the student is 4 January 30, 2020 notified of the referral, and the notice of the hearing shall be sent by registered mail to the last known address of the student as found on the Faculty’s records and the student’s University of Manitoba e-mail address. The notice from the Chair shall include a statement to the effect that if the allegations contained in the referral are established to the satisfaction of the PUC, the student may be required to withdraw from the Program. The notice should also include a statement indicating that if the student wishes to request a deferral of the hearing in order to adequately prepare, they may do so, and such request will be considered in accordance with the principles of fairness and reasonability.

6.2 The student may provide a written response to the alleged grounds. Such written response shall be provided to the chair of the PUC no later than five (5) working days before the hearing date.

6.3 The student also has the right no later than five (5) working days before the hearing date to raise concerns to the Chair in writing about any member on the PUC whom the student believes will not be able to be objective in the consideration of their case. Where the Chair of the PUC receives such concerns, they shall, before the hearing, convey the concerns to every member of the PUC and inform any member identified by the student that they have the right to respond to the concerns in writing. The Chair shall convene the PUC, excluding any Committee member identified by the student, to determine whether or not a change in the membership of the PUC shall be made. In the event that the quorum specified in 4.3 is not achieved for this determination, the remaining Committee membership may decide this matter and, if circumstances dictate, the Chair may make this determination alone. Where the PUC or its Chair decide that a change in membership is required, a replacement or replacements will be made in accordance with 4.2 unless the quorum specified in 4.3 exists.

6.4 A member of the PUC shall not be disqualified from sitting as a member of the PUC hearing the matter by reason only that such member has had previous contact with the student or has prior personal knowledge of the matter.

6.5 If the student fails to respond to reasonable attempts by the Chair of the PUC to proceed with the hearing, the hearing may proceed in absentia.

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7.0 Hearing Procedures

7.1 The student may appear in-person and may choose to be represented or accompanied by a Student Advocate, a GSA representative, legal or other counsel. Should the student choose to be represented or accompanied by a Student Advocate, legal or other counsel, written notification must be provided to the Chair no later than five (5) working days prior to the hearing date. In cases where legal counsel is involved, they shall act solely in an advisory capacity.

7.2 The Program may also choose to have legal counsel present to act in an advisory capacity during the proceedings and where it does so, the Chair of the PUC shall advise the student of this fact no later than five (5) working days prior to the hearing date. For the purposes of certainty, the PUC’s decision, based on its application of this bylaw to the facts considered during the hearing, is its own decision made independently, and not that of legal counsel.

7.3 The student and the Program, and/or their respective representatives (excluding legal counsel) shall have the right to call, hear and cross-examine witnesses, to submit other evidence, and to have access to all documents submitted to the PUC for consideration. Written notice to call any witness shall be given to the other party prior to the hearing. All documentary evidence submitted for consideration by the PUC must be supplied with notice to the other party prior to the hearing. 5 January 30, 2020

7.4 The hearing shall be closed to all persons except the members of the PUC, the student, the designated representatives of the student and/or Program, and any witness as they are called.

7.5 The student, who is the subject of the hearing, shall not be required to give evidence but if the student elects to do so, then members of the PUC may question the student.

7.6 A simple majority of Committee members hearing the matter is required for any finding or for the determination of the appropriate disposition of the matter. 7.7 The Chair of the PUC shall vote only to break a tie.

7.8 Members of the PUC shall be bound by confidentiality in respect of information received in Committee. Information will be disclosed only as is reasonably necessary to implement the investigation, the resolution or the terms of any disposition imposed, or as required by law.

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8.0 Disposition of the Matter

8.1 After hearing all the evidence, the PUC shall meet in closed session to:

a) consider the evidence;

b) make its findings using a balance of probabilities standard (i.e. the claim against the student is more likely to be true than not true based on the evidence presented);

c) determine the appropriate disposition of the matter if the allegations are established to the satisfaction of the PUC;

d) dismiss the matter if the allegations are not established to the satisfaction of the PUC; and

e) make any other recommendations that the PUC deems appropriate based on the hearing process.

8.2 The PUC may make any disposition it deems appropriate in the circumstances. Without limiting the generality of the foregoing, the following options, alone or in combination, are available to the PUC:

a) determine that no further action be taken;

b) allow the student to remain in the Program and attach conditions prescribing future conduct by the student. Such conditions to remain in effect for any period of time the PUC deems appropriate;

c) reprimand the student in writing;

d) recommend to the Faculty of Graduate Studies that the student be suspended from the program and attach conditions that must be fulfilled before resuming the program;

e) recommend to the Faculty of Graduate Studies that the student be Required to Withdraw from the Program with no right to apply for re-admission to the program.

f) require notation regarding the disposition of the matter to be placed on the student’s transcript, to include the period of time before which the student can request the removal of such notation (but not to exceed more than 5 years).

8.3 The Chair of the PUC shall, within five (5) working days, convey in writing the disposition to both parties with a copy to the Dean of the Faculty of Graduate Studies (or designate) and Head, Department of Occupational Therapy, College of Rehabilitation Sciences.

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9.0 Appeals

9.1 If the student wishes to appeal the disposition of the PUC, such appeal may be made to the Senate Committee on Academic Appeals, Office of the University Secretary, 312 Administration Building, in accordance with the appeal policy and procedures of that body.

9.2 In the event of an appeal, the implementation of any decision of the PUC may be suspended until the matter has been disposed of by the Senate Appeals Committee. 6 January 30, 2020

9.3 Notwithstanding the above, if the President of the University (or designate) is satisfied that just cause exists to suspend the student while the matter is being determined, the student may be suspended from participating in any program of the University while the matter is under review and appeal.

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10.0 Records

10.1 A record of any finding of professional unsuitability and/or disposition related thereto shall be kept on the student’s academic file. All information relating to the case shall be retained confidentially in the office of the Dean of the Faculty of Graduate Studies accordingly to the University’s Common Records Schedule.

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11.0 Amendments

11.1 This By-Law may be amended by Senate alone, or by Senate after approval of such amendment(s) by Occupational Therapy Departmental Council.

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12.0 Review

12.1 A formal review of this By-Law will be conducted every ten (10) years.

Approved by MOT Program Committee on December 12, 2019
Approved by CoRS Executive Council on January 30, 2020
Approved by Senate on November 4, 2020 

Policy #5	Student certification requirements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline the documentation and certifications required of students prior to their involvement in clinical education activities.

Policy Statements

5.1 Successful applicants who accept an offer of admission to the Master of Physical Therapy program must submit the following documentation to the Administrative Coordinator of Clinical Placements in accordance with the issue dates and deadlines provided with their offer of admission. These documents are required in order for students to engage in clinical education activities once the program commences.

5.1.1 Completed Health Questionnaire, Immunization Status/Record and MIMS Release of Information Form

5.1.2 Current Basic Life Support (BLS) for Healthcare Provider (C) certification (or higher) provided by an instructor certified through the Heart & Stroke Foundation.

5.1.3 Criminal Record Check including a vulnerable persons’ screen

5.1.4 Child Abuse Registry Check

5.1.5 Adult Abuse Registry Check

5.1.6 Membership card or receipt verifying current registration with the College of Physiotherapists of Manitoba

5.2 Students are required to complete “Mask Fit Testing” using the mask designated by the Master of Physical Therapy program. Students may have the opportunity to complete this testing through the Master of Physical Therapy program but will be responsible for the cost of testing. Students should refer to relevant information included with the offer of admission. Certification must remain current during all clinical placements.

5.3 Students must attend the Personal Health Information Act Session and must be able to present proof of attendance (PHIA Card) at their Clinical Education Sites prior to beginning their clinical placements.

5.4 Students must attend the WRHA Routine Practices session and must be able to present a completed checklist indicating demonstration of effective infection prevention and control procedures.

5.5 Returning students are required to annually:

5.5.1 Review and update immunization(s) as necessary. Annual physical and dental examinations are recommended.

5.5.2 Acquire re-certification in Basic Rescuer Cardio Pulmonary Resuscitation through a course provided by a Heart and Stroke certified instructor. Documentation of this recertification must be provided to the Academic Coordinator of Clinical Education by the date published yearly in information provided to students.

5.5.3 Register as a student member with the College of Physiotherapists of Manitoba.

5.5.4 Complete a Criminal Records Check (including a vulnerable persons’ screen), Child and Adult Abuse registry checks. Documentation of the results of these tests must be provided to the Administrative Coordinator of Clinical Placements by the date published annually in information provided to students.

5.5.4.1 Students with a positive Criminal Record, Child or Adult Abuse Registry Check will be asked to provide details to the Head, Department of Physical Therapy (or designate).

5.6 It is the student's responsibility to ensure that all of the foregoing information/documentation is acquired. The student is also responsible for payment of all costs incurred by this process.

5.7 Health Forms will be kept in the student file in a secure location within the Rady Faculty of Health Sciences Immune Status Program.

5.8 Confirmation of completion of all other requirements by each student (e.g. copies of these documents) will be held securely within the College of Rehabilitation Sciences offices.

5.9 Students are required to maintain and present original copies of all required documents as determined by their assigned Clinical Education Sites.

5.10 Clinical Education Sites may require other conditions to be met by students prior to starting a clinical placement. Students are responsible for meeting these requirements and for any related costs.

Policy #2	The required mix of clinical education experiences for each student
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To outline the mix of clinical placement experiences (clinical areas, settings, and patient age groups) required by students to prepare them as effective graduate physiotherapists and for the program to meet accreditation standards (Physiotherapy Education Accreditation Canada Accreditation Standards, 2012, rev. 2017.).

During their time in the University of Manitoba Master of Physical Therapy program, each student will be allocated a set of clinical placements that ensures they receive the following clinical education experiences:

2.1 Each student shall complete a minimum of 1,025 hours of physiotherapy clinical placements.

2.2 Each student shall complete a minimum of 100 hours involving direct clinical care of patients in each of the following essential areas of practice:

2.2.1 Cardiovascular and Pulmonary conditions

2.2.2 Neurological conditions

2.2.3 Musculoskeletal conditions. (All students must complete a minimum of one outpatient orthopedic clinical placement.)

2.3 Each student shall complete a minimum of 100 hours of clinical experience in each of the following essential settings:

2.3.1 Acute Care

2.3.2 Rehabilitation/Long term Care

2.3.3 Ambulatory Care

2.4 While on clinical placement in the above areas, each student will gain significant clinical experience working with:

2.4.1 Patients with multisystem conditions

2.4.2 Patients from at least two of the following three age groups:

2.4.2.1 Pediatric (0-17 years)

2.4.2.2 Adult (18-64 years)

2.4.2.3 Older adult (65 years and older)

2.5 In addition, many students will have the opportunity to experience a non-traditional model clinical placement, including:

2.5.1 Multiple students to one Clinical Instructor

2.5.2 Multiple Clinical Instructors to one student

2.5.3 Senior-junior student pairing with one Clinical Instructor

2.5.4 Student-led clinics in neuro, manual therapy, and sports

2.5.5 Emerging role placements in primary care and cancer care

2.5.6 Interprofessional collaborative placements

2.5.7 Rural placements including Northern/remote/Indigenous communities

2.5.8 Research placements

Policy #17	Support, communication, and monitoring processes during clinical placements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To identify roles and responsibilities of physical therapy faculty who support the teaching/learning experience during clinical placements and serve as a resource by monitoring the clinical education experience and representing the University of Manitoba, Department of Physical Therapy.

Policy Statements

17.1 The Academic Coordinator of Clinical Education will provide guidance, support, facilitation and mediation to students, Clinical Instructors and Program Advisors to facilitate successful clinical placements for students.

17.2 Students and Clinical Instructors may contact the Academic Coordinator of Clinical Education at any time throughout a clinical placement regarding any clinical placement matter.

17.3 In the event of problems with student performance, both the student and Clinical Instructor must inform the Academic Coordinator of Clinical Education as early as possible.

17.4 Students in the Master of Physical Therapy program are assigned a Program Advisor who follows their progress through both the academic and clinical components of the program. The Program Advisor should contact their students at the placement midterm to check on their progress and how they are managing generally. Students may contact their Program Advisor to discuss their progress at any time during the clinical placement. Program Advisors may advise the student but should also inform the Academic Coordinator of Clinical Education as soon as possible if there are any issues requiring intervention.

Policy #22	Use of social media
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose: To provide students in the Master of Physical Therapy program with guidance regarding safe and professional use of social media, respecting legal, ethical, and regulatory requirements of the profession, University and College of Physiotherapists of Manitoba.

Policy Statements

The following statements are based on the College of Physiotherapists of Manitoba Guideline: Use of Social Media (Jan 26, 2017).

22.1 Students should assume that all content on the Internet is public and accessible to all, including professional contacts, colleagues, clients/patients, and employers.

22.2 Students must not post information on-line that relates to an actual client/patient. They must ensure compliance with legal and professional obligations to maintain privacy and confidentiality and be aware that an unnamed client/patient may still be identified through a range of other information, such as a description of their clinical condition or area of residence.

22.3 Students must refrain from providing clinical advice to specific clients/patients through social media.

22.4 Students must protect their own reputation, the reputation of the profession and the University, and the public trust by not posting content that could be viewed as unprofessional.

22.5 Students are expected to be mindful of their internet presence and be proactive in removing content posted by self or others which may be viewed as unprofessional. Students are reminded that when they self-identify as a physiotherapist, they are using title and are subject to the standards of the College of Physiotherapists of Manitoba, even on personal accounts. Students must refrain from establishing personal connections with clients/patients or persons closely associated with them on-line, as this may hinder their maintenance of appropriate professional boundaries and compromise their objectivity.

22.6 Students must refrain from seeking out client/patient information that may be available on-line without prior consent, as individuals are entitled to a reasonable expectation of privacy. While students are expected to adhere to all of their relevant legal obligations under PHIA with respect to the collection of personal health information, they should also refrain from seeking out other types of non-protected information on-line without prior consent.

22.7 Students must read, understand, and apply the strictest privacy settings necessary to maintain control over access to their own personal information.

22.8 Students must comply with relevant Clinical Education Site policies regarding social media usage and general policies on computer and internet usage.

22.9 Students should recognize that social media platforms are constantly evolving and be proactive in considering how professional expectations apply in any given set of circumstances.

Policy	Application for exemption from the clinical education ‘Beyond-the- Perimeter’ requirement
Approved By	Clinical Education Committee
Approval Date	November 29, 2018

Purpose

To provide students in the Master of Physical Therapy program with guidance regarding safe and professional use of social media, respecting legal, ethical and regulatory requirements of the profession, University and College of Physiotherapists of Manitoba.

Policy statements

21.1 To request exemption from the “Beyond-the-Perimeter” clinical education requirement, students must apply in writing to the Academic Coordinator of Clinical Education. The letter must outline the reasons for the request, and the length of the requested exemption. Students will provide a copy of this request to their Program Advisor and the Head of the Department of Physical Therapy.

21.2 Students can apply for the exemption at any time during the Master of Physical Therapy program, however it will not apply to clinical placements that were posted prior to its submission.

21.3 A committee consisting of the Head, Department of Physical Therapy, the Academic Coordinator of Clinical Education and the student’s Program Advisor and will review the request and make a determination. The student will then be informed.

21.3.1 Honouring this exemption shall not disadvantage another student in the Master of Physical Therapy program. Therefore, it is possible that a student receiving this exemption may be required to defer their clinical placement to the end of the program.

Policy	Assignments and projects during clinical placements
Approved By	Clinical Education Committee
Approval Date	November 29, 2018

Purpose

To outline expectations related to assignments and projects during clinical placements.

Policy statements

10.1 Site Specific Assignments and Projects

10.1.1 Site-specific assignments and special projects may be included as part of the clinical placement experience. These projects should be based on the learning objectives for the clinical placement. University guidelines for assignments and special projects include:

10.1.1.1 Assignment topic and format should be discussed and agreed upon by the Clinical Instructor and the student early in the clinical placement (before midterm).

10.1.1.2 Assignments should be relevant to the current clinical placement.

10.1.1.3 Assignments should be designed to facilitate personal and professional growth of the individual student.

10.1.1.4 Assignments should not duplicate traditional academic course assignments.

10.2 Time requirements for assignments should not prevent the student from participating in activities at the Clinical Education Site. The student may be expected to complete some work related to the assignment outside of work hours. It is expected that the student and their Clinical Instructor will be able to negotiate reasonable expectations re time commitments.

10.3 Library Privileges:

10.3.1 Students who are provided with library privileges at the Clinical Education Site to facilitate the completion of assignments and projects are subject to the rules and regulations of the Clinical Education Site library.

10.3.2 All books and materials must be returned to the library by the end of the clinical placement.

10.3.3 The student is responsible for payment of any fines incurred due to overdue material books that they have borrowed.

10.4 Computer & Internet Access:

10.4.1 Students using computers and/or internet services at the Clinical Education Site to facilitate the completion of assignments and/or projects are subject to the rules and regulations governing the use of computers and internet services at the Clinical Education Site.

Policy	Cancellation of clinical placements
Approved By	Clinical Education Committee
Approval Date	November 29, 2018

Purpose

To outline the process for cancellation of a clinical placement by the Clinical Education Site or the Academic Coordinator of Clinical Education.

Policy statements

14.1  Cancelation of a clinical placement:

14.1.1 The Clinical Education Site personnel or the Academic Coordinator of Clinical Education and should attempt to notify each other of a clinical placement change or cancellation as soon as possible.

14.1.2 It is recommended that whenever possible, clinical placement changes or cancellations occur no later than four weeks prior to the beginning of a clinical placement.

14.1.3 In the event of a clinical placement being changed or cancelled, the location and type of the replacement clinical placement may be different from the initially allocated clinical placement.

14.1.4 If a placement is cancelled, the student will be notified by the Academic Coordinator of Clinical Education. Every attempt will be made to find the student an alternate clinical placement in the same time slot, however this may delay the student’s graduation date.

Policy	Contact with clinical education sites
Approved By	Clinical Education Committee
Approval Date	November 29, 2018

Purpose

To outline the requirements for students regarding contact with Clinical Instructors prior to the commencement of a clinical placement.

Policy statements

4.1 Students engaged in a clinical placement as a required part of their program are covered for liability under the University of Manitoba’s General Liability Insurance with the Canadian Universities Reciprocal Insurance Exchange (CURIE). Written documentation relating to the liability coverage is available in the form of a memo from the University of Manitoba administration.

4.1.1 Procedure: Anyone requiring a copy of this memo should contact the Academic Coordinator of Clinical Education.

4.2 Students engaged in a clinical placement in Manitoba as a required part of their program are covered for injuries sustained in the course of and arising out of the clinical placement under the Workers Compensation Act (Manitoba), in accordance with and subject to its provisions.

4.2.1 Procedure: In the event of a student being injured during a clinical placement, the Clinical Instructor or Clinical Education Site Leader should complete any necessary incident reports and promptly contact the Academic Coordinator of Clinical Education to ensure that coverage under the Workers Compensation Act is secured.

4.3 Students in the University of Manitoba Master of Physical Therapy program who are not Manitoba residents who engage in a clinical placement outside Manitoba may not be covered by the Workers Compensation Act (Manitoba). In this event, these students will be covered by an alternative policy through the University of Manitoba.

4.3.1 Procedure: On an annual basis, the Administrative Coordinator of Clinical Placements will inform the University of Manitoba Risk Management & Security Services of the number of non-Manitoban students who completed clinical placements outside of Manitoba during the last year.

4.4 International students in the University of Manitoba Master of Physical Therapy program who are attempting to arrange a clinical placement in their own country-of-origin may experience difficulties or be denied the clinical placement because the University is not able to guarantee that they will have workers compensation coverage during the clinical placement. Alternative arrangements can sometimes be made to cover these clinical placements, but this is done on a case-by-case basis. Students are encouraged to contact the Academic Coordinator of Clinical Education at the earliest opportunity to determine if any such alternative arrangements are possible.

Policy	Clinical education hours
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To provide guidelines as to how clinical placement hours are determined in order that each student shall complete the required minimum 1025 hours of clinical placements.

Policy statements

9.1 Clinical education hours: The Canadian Alliance of Physiotherapy Regulators and Physiotherapy Education Accreditation Canada require students to successfully complete a minimum of 1025 hours of clinical placements in order to meet requirements for graduation and attempting the written component of the Physiotherapy Competency Exam. The University of Manitoba Master of Physical Therapy program includes 1,088 clinical placement hours (29 full-time weeks x 37.5 hours/week). This represents 63 hours more than the total required, ensuring all students obtain the mandated clinical education time.

9.1.1 It is anticipated that students will need to spend additional hours in preparation, reflection and documentation of their clinical placement practice.

9.1.2 Students' working hours on-site (including lunch, coffee breaks, daily work schedule, etc.) are determined according to the policies/regulations of the Clinical Education Site.

9.1.3 Students may be required to work evenings and weekends in accordance with the requirements of the Clinical Education Site.

9.1.4 Students may accumulate banked time in accordance with Clinical Education Site policies.

9.2 Absenteeism:

9.2.1 Attendance by students in clinical placements is mandatory. If a student will be absent from the clinical placement for any reason, they must notify their Clinical Instructor (or Clinical Education Site Leader if appropriate) and the Academic Coordinator of Clinical Education as soon as possible, and preferably prior to the absence. Approval for student non-attendance is jointly made by the Clinical Instructor (or Clinical Education Site Leader, if appropriate) and the Academic Coordinator of Clinical Education. Possible acceptable reasons for absence may include personal illness/injury, illness or death of a family member, appointments, religious holidays, University committee work, and activities relating to provincial/national/international representation.

9.2.2 Illness/injury: If a student is absent for three or more consecutive days because of illness, they may be required to submit a certificate from a licensed physician/dentist to their Clinical Instructor upon their return to the Clinical Education Site, with a copy forwarded to the Academic Coordinator of Clinical Education. The student should consult with the Clinical Instructor and the Academic Coordinator of Clinical Education to determine if this will be required.

9.2.3 Compassionate reasons: If a student is absent for compassionate reasons, Clinical Instructor and the Academic Coordinator of Clinical Education should be informed. If the allowed number of days of absence from the clinical placement is exceeded, then policy 9.3relating to making up time applies.

9.2.4 Religious holidays: If a student intends observing a religious holiday other than those specified as statutory holidays, they must inform their Clinical Instructor and the Academic Coordinator of Clinical Education before the beginning of the clinical placement. If the allowed number of days of absence from the clinical placement are exceeded, then the policy relating to making up time applies.

9.2.5 University/professional committee work: A student representing physical therapy as a member of a University committee or a professional organization will not be required to make up time for absence from the clinical placement incurred by one of these meetings. The student is responsible for informing their Clinical Instructor and the Academic Coordinator of Clinical Education as soon as possible of the dates of meetings (in advance when possible).

9.2.6 Provincial/national/international representation: A student who is involved in sports, arts or other activities at a provincial, national or international level and is required to participate/compete in an associated event during their clinical placement, should inform the Academic Coordinator of Clinical Education as soon as possible of the dates of the activities/competition. If the allowed number of days are exceeded, then policy 9.3 relating to making up time applies, or the student may request that they be allowed to complete the clinical placement at a time that does not interfere with any scheduled activities/competitions.

9.2.7 Educational events: Requests for time away from the Clinical Education Site to attend conferences, workshops, or other educational activities not directly related to the clinical placement may be considered. The student and should consult with the Clinical Instructor and the Academic Coordinator of Clinical Education who will consider the request and make recommendations about the suitability of the activity.

9.2.8 Appointments: Students should endeavor to arrange all appointments outside of clinical placement hours. All non-emergency doctor/dentist appointments should be arranged to avoid conflicting with clinical placements. If a student is required to attend an emergency appointment, notice should be given as soon as possible to the Clinical Instructor and the Academic Coordinator of Clinical Education.

9.2.9 Personal Needs: It is expected that students will not ask for shortened workdays to accommodate personal needs and/or job commitments.

9.3 Make-up time:

9.3.1 In general, a student should endeavour to ‘make-up’ all time missed from clinical placements. It is preferable if make-up time can be accommodated within the current clinical placement by working additional hours, evenings, or weekends. Make-up hours should be compatible with the focus of the program and if possible, allow contact with clients and the continual development of knowledge and skills. Make-up time should not be designed to simply ensure the student fulfills a minimum hourly requirement but should fit with the clinical education objectives.

9.3.2 If a student has not been able to schedule make-up time within the current clinical placement (i.e. if additional time cannot be accommodated due to the nature of the Clinical Education Site/program and/or if absences occur toward the end of a clinical placement), a student may be required to make-up time missed from clinical placements if the total days absent from the regularly scheduled clinical placement time exceeds two days. This decision is made by the Clinical Instructor and Academic Coordinator of Clinical Education and is informed by the student’s achievement of the clinical placement objectives.

Policy	Clinical education policies – general information
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To serve as a guide for faculty, site leaders, Clinical Instructors, and students during clinical placements.

Policy statements

1.1 The Master of Physical Therapy Program Clinical Education Policies will be posted on the College of Rehabilitation Sciences web site.

1.2 Students must comply with the policies and procedures of the particular Clinical Education Site at which they are completing their clinical placements.

1.3 The Master of Physical Therapy Program Clinical Education Policies should be used as adjunct guidelines in consideration of existing Clinical Education Site policies and procedures.

1.4 In the event of a conflict between the Clinical Education Site policies and procedures and the Master of Physical Therapy Program Clinical Education Policies, the Academic Coordinator of Clinical Education should be informed as soon as possible.

Policy	Clinical education site approval
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline requirements for approval of Clinical Education Sites providing clinical placement opportunities for students in the Master of Physical Therapy program.

Policy statements

20.1 Each site is required to submit a National Association of Clinical Education Professional Practice Site Profile Form, to be completed by the appropriate individual at the site. These forms will be implemented when sites are approved, and every five years thereafter.

20.1.1 Professional Practice Site Profile Information: Site Contact Information, Type of Facility, Insurance Information, Facility Ownership, Continuing Professional Education Access, Type of Charting, Dress Code, Parking, Accommodation, Staffing, Requirements for Criminal Record and other Checks/Mask Fit testing/Immunizations, Other Health Professionals On-site, Diagnostic Categories of Patients, Special Programs, Clinics, Student Learning Opportunities in terms of CVP/Ortho/Neuro/Specialities/Other.

20.2 In some situations, based on sufficient information, sites may provide a clinical education opportunity for a student prior to all documentation being completed. In this situation the Academic Coordinator of Clinical Education or designate may conditionally approve the site for use.

20.3 Sites approved by other university programs will be considered approved.

Policy	Clinical placement grades
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline the decision process for assigning a pass or fail in a clinical placement and procedures related to failure of a clinical placement/course.

Policy statements

15.1 It is the responsibility of the Clinical Instructor to assign the final grade for the clinical placement on the Assessment of Clinical Practice form on HSPnet.

15.2 The Clinical Instructor must inform the Academic Coordinator of Clinical Education as soon as possible regarding any student performance issues that put the student at risk of failure, to enable the development of a robust remediation process to directly address the student’s identified deficiencies.

15.3 Failure of a clinical placement:

15.3.1 A Clinical Instructor will not assign a student a failing grade for a clinical placement without prior, direct involvement of the Academic Coordinator of Clinical Education.

15.3.2 Students may be permitted to repeat one failed clinical placement over the duration of the program.

15.3.3 A student receiving a fail in a clinical placement must successfully repeat that clinical placement prior to progressing to the next clinical education course.

15.3.4 Students who fail more than one clinical placement will be required to withdraw from the program.

Note: Because clinical education courses are closely juxtaposed with academic components, students may proceed into clinical placement without having received official final grades in preceding academic course work.

Policy	Clinical placements outside of Manitoba but within Canada – arrangements for accommodation, transportation and food
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To describe the process and resources available to students participating in clinical placements outside of Manitoba but within Canada.

Policy statements

Purpose: To describe the process and resources available to students participating in clinical placements outside of Manitoba but within Canada.

7.1 Students may complete clinical placements outside of Manitoba, however their first placement in first year must be located in Manitoba.

7.2  There is no reimbursement of any costs related to clinical placements outside Manitoba (with the exception of the Nunavut placement sponsored by Ongomiizwin Health Services).

7.3 Students may submit applications to the Academic Coordinator of Clinical Education for clinical placements outside of the University of Manitoba’s provincial catchment area. Upon approval of the application, the Academic Coordinator of Clinical Education will forward it to the appropriate university physical therapy educational program.

7.4 If a student wishes to access out-of-catchment clinical placements, they will be responsible to pay the associated application fee. The student must provide a cheque payable to the University of Manitoba at the time of submission of the clinical placement request form. If the cheque is returned by the bank for non-sufficient funds, the student will be charged the appropriate non-sufficient fund fee, in addition to the clinical placement fee.

7.5 Students will follow the procedure for applying for the out-of-catchment clinical placement.

7.6 Any additional costs incurred/ levied by a Clinical Education Site outside of the University of Manitoba’s catchment area (e.g. administrative fee) will be the student’s responsibility.

7.7 Sites with no pre-established legal agreement or affiliation with the University of Manitoba:

7.7.1 If a student wishes to complete a clinical placement at a site that does not have a pre-established affiliation or legal agreement with the University of Manitoba, the student should arrange to meet and discuss the matter with the Academic Coordinator of Clinical Education.

7.7.2 Requests for new Clinical Education Sites must be made a minimum of 6–8 months in advance of the anticipated clinical placement dates.

7.7.3 The learning objectives and location of any clinical placement must meet the approval of the Department of Physical Therapy and the University of Manitoba.

7.7.4 A student who requests a clinical placement at a specific site that does not have a pre-existing legal agreement and affiliation with the University of Manitoba should be aware that a Clinical Education Site usually requires a contractual (legal) arrangement with the University of Manitoba prior to the student being permitted to commence their clinical placement. There is no guarantee that the University of Manitoba will be successful in establishing such a contractual arrangement with the new site, in which case the student should be prepared to select an alternate Clinical Education Site.

Policy	Clinical placements within Manitoba - arrangements for accommodation, transportation and food
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To describe the process and resources available to University of Manitoba students participating in clinical placements within Manitoba.

Policy statements

6.1 Students are responsible for all costs related to clinical placements within the Winnipeg perimeter, including transportation costs.

6.2 Each student should be prepared to complete a minimum of one clinical placement beyond the Winnipeg perimeter.

6.2.1 To prevent undue financial hardship, students receiving a clinical placement outside Winnipeg but within Manitoba will receive support for some transportation and accommodation costs.

6.2.2 Students must consult with the Academic Coordinator of Clinical Education prior to the beginning of the clinical placement to determine if and how the reimbursement policies apply to their specific situation.

6.2.3 The Administrative Coordinator of Clinical Placements will make accommodation arrangements for students who are placed outside of Winnipeg for clinical placements. Once a student has confirmed in writing that they do or do not require accommodation, no changes are allowed.

6.2.4 If a student chooses to arrange their own accommodation, they must inform the Administrative Coordinator of Clinical Placements as soon as possible. In such cases, the student must have the cost of accommodation pre-approved by the Academic Coordinator of Clinical Education or the Administrative Coordinator of Clinical Placements or they will not be reimbursed. Generally, students will not be reimbursed for accommodations costs that exceed those that can be arranged by the University.

6.2.5 If the University has arranged a place of accommodation and the student decides to move from this place of accommodation, they must inform the Academic Coordinator of Clinical Education before initiating the move. The Academic Coordinator of Clinical Education will determine if the change will be approved and paid for, given the specific circumstances.

6.2.6 In situations where the student is on clinical placement outside of Winnipeg and the student chooses to stay with family or friends and commute to the Clinical Education Site rather than stay at accommodation arranged by the University closer to the clinical placement site, the student must choose to either be reimbursed for transportation costs OR to have accommodation provided/paid for by the University.

6.2.7 To be reimbursed for expenses incurred during the clinical placement, students must submit original receipts for expenses along with the completed Travel Reimbursement Form to the Administrative Coordinator of Clinical Placements.

6.3 Students allocated to Clinical Education Sites beyond the perimeter will be reimbursed for transportation expenses as follows:

6.3.1 Transportation expenses reimbursed will be to an amount equal to, or less than, the cost of one round-trip bus fare between Winnipeg and the Clinical Education Site (as outlined below). There is no reimbursement for travel to and from the Clinical Education Site regardless of location.

6.3.2 If a student chooses to travel by car, the student will be reimbursed for actual gas costs unless such costs are greater than the cost of one round trip bus fare (which is the maximum allowable amount).

6.3.3 If two or more students travel together by car to and from the Clinical Education Site, only the equivalent of one student’s round-trip bus fare will be reimbursed.

6.3.4 If a student chooses to commute by car to and from a Clinical Education Site beyond the Winnipeg perimeter (e.g. Steinbach, Portage La Prairie, Beausejour or Selkirk) OR wishes to reside at a family/friend’s home and commute to a Clinical Education Site in a rural location rather than stay at accommodation close to the Clinical Education Site, then the student will be reimbursed for transportation costs. These will be based on original gas receipts up to and not exceeding $12/day of attendance at the clinical placement. Students are required to complete the “Form to Complete for Commuting” available on the clinical education course page of the University web-based educational platform or from the Administrative Coordinator of Clinical Placements.

6.3.5 Students are strongly discouraged from commuting to Clinical Education Sites beyond a 75-kilometre radius of their place of lodging.

6.3.6 In situations where the student is on clinical placement outside of Winnipeg and is required to use their car to participate in, or complete certain aspects of the clinical placement, and the Clinical Education Site is unable to provide financial support for transportation, the student should consult with the Academic Coordinator of Clinical Education to determine if the costs of transportation are eligible for reimbursement. If the Academic Coordinator of Clinical Education determines that the travel is essential, the student may be reimbursed on a per kilometre basis consistent with University of Manitoba staff policy. This amount will not exceed $50.00 per clinical placement. Note: Students are advised not to transport clients in their car unless they have obtained appropriate insurance coverage.

6.3.7 If a student is placed with the J.A. Hildes Northern Medical Unit, the Unit will pay the costs for return airfare to and from Rankin Inlet, Nunavut and the cost of one return airfare to and from a remote community serviced by the Physical Therapist (dependent on yearly negotiations).

6.4 Accommodation expenses allotted will be to an amount less than or equal to the cost of accommodations arranged by the University.

6.4.1 If there is a cost for accommodation, the individual providing lodging must submit a written invoice to the University of Manitoba c/o the Administrative Coordinator of Clinical Placements indicating the dates and cost of accommodation.

6.4.2 Invoices should be submitted as soon as possible and no later than 6 weeks after completion of the clinical placement. Invoices received after this date will not be processed.

6.4.3 Wherever possible, attempts will be made to have direct billing to the University to avoid the need for students to be reimbursed.

6.4.4 Students are responsible for payment of refundable damage deposits. Students are also responsible for payment of any damages to the place of accommodation that occur during their stay.

6.4.5 If a student is invited to travel with their Clinical Instructor during a clinical placement, and the trip will involve an overnight stay(s), the student or clinical instructor should consult with the Academic Coordinator of Clinical Education to determine if support is available to assist with the costs of accommodation.

6.5 Food costs will not be reimbursed:

6.5.1 If the cost of accommodation also includes food, and the cost of food is not specified, the student will be responsible to pay a predetermined amount per day in food costs.

6.5.2 Depending on the situation, the student may have to pay for food costs in an advance lump sum at the beginning of the clinical placement/accommodation period. It is the student’s responsibility to ensure this fee is paid. Students for whom this will cause financial or other difficulty must inform the Academic Coordinator of Clinical Education immediately, so that arrangements for alternate accommodation can be made where possible.

6.6 Clinical Education Sites with no pre-established legal agreement or affiliation with the University of Manitoba:

6.6.1 If a student wishes to complete a clinical placement at a site that does not have a pre- established affiliation or legal agreement with the University of Manitoba, the student should arrange to meet and discuss the matter with the Academic Coordinator of Clinical Education.

6.6.2 Requests for new Clinical Education Sites must be made a minimum of 6-8 months in advance of the anticipated clinical placement dates.

6.6.3 The learning objectives and location of any clinical placement must meet the approval of the Department of Physical Therapy and the University of Manitoba.

6.6.4 A student who requests a clinical placement at a specific site that does not have a pre-existing legal agreement and affiliation with the University of Manitoba should be aware that a Clinical Education Site usually requires a contractual (legal) arrangement with the University of Manitoba prior to the student being permitted to commence their clinical placement. There is no guarantee that the University of Manitoba will be successful in establishing such a contractual arrangement with the new site, in which case the student should be prepared to select an alternate Clinical Education Site.

Policy	Deferral of clinical placements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To provide guidelines as to how requests for changes to Clinical education dates/times will be addressed.

Policy statements

18.1 Any requests for postponed/deferred clinical education time must be presented in writing to the Academic Coordinator of Clinical Education at least 6 weeks in advance of the scheduled start date of the clinical placement. The request will only be considered for extenuating circumstances hich do not include job commitments or personal travel plans.

Policy	Delays or disruptions in clinical placements due to extraordinary circumstances
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To provide guidance regarding steps to be taken in the event of delays or disruptions in a clinical placement due to extraordinary circumstances (e.g. job action, infectious disease, natural disaster).

Policy statements

16.1 The Clinical Education Site’s policy will guide the University’s decision in dealing with delays or disruptions due to extraordinary circumstances.

16.2 In the event of an extraordinary circumstance, students are to contact the Academic Coordinator of Clinical Education at the first sign of clinical placement disruption.

16.3 Where possible, clinical placements that are disrupted or delayed due to extraordinary circumstances will be accommodated for on a case-by-case basis.

16.3.1 The make-up hour’s policy (9.3) will be used to help guide decisions.

16.3.2 The Academic Coordinator of Clinical Education will discuss with the Clinical Instructor and/or Clinical Education Site Leader the options that are available both prior to, and during any extraordinary circumstance.

16.4 Possible Options:

16.4.1 The Academic Coordinator of Clinical Education will discuss with the Clinical Instructor the possibility of having the student resume the clinical placement after the delay or disruption ends.

16.4.2 Students may be permitted to work on approved projects relevant to the clinical placement, resources permitting.

16.4.3 The Academic Coordinator of Clinical Education will provide an alternate clinical placement at a later date. Every effort will be made to provide a clinical placement prior to the student’s anticipated date of graduation.

Policy	Evaluation of student performance on clinical placement
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline evaluation processes involved in the clinical education program.

Policy statements

11.1.1 During the first few days of the clinical placement, the student should collaborate with their Clinical Instructor to discuss their learning objectives for the clinical placement and complete the Clinical Learning Contract. The student and their Clinical Instructor should review progress in meeting the objectives at the midterm and final.

11.1.2 The student should continually update their Clinical Skills Checklist during the clinical placement to ensure they have an accurate record of the skills they have observed and practiced. This list should be reviewed at the midterm and final to inform discussion regarding the student’s progress in meeting objectives and will also be used by the program to monitor relevance of teaching content.

11.1.3 Student evaluation is completed by the Clinical Instructor using the Canadian Physiotherapy Assessment of Clinical Practice instrument (ACP) on HSPnet at midterm and final. The student also completes self-reflection regarding their performance using their own copy of the ACP on HSPnet at midterm and final. HSPnet enables the student and Clinical instructor to view both documents simultaneously at midterm and final, which facilitates discussion of perceptions and achievement of performance objectives.

11.1.4 It is recommended that Clinical Instructors enter specific feedback in each comment box of the ACP, indicating areas of strength and areas requiring   improvement.

11.1.5 Any areas of concern should be clearly documented in the ACP and discussed with the student to determine a specific plan for the student to improve their performance.

11.1.6 The Academic Coordinator of Clinical Education should be informed by midterm at the latest if there are any concerns about student performance. The Academic Coordinator of Clinical Education is available and ready to assist in the development of the plan to facilitate improvement of the student’s performance.

11.1.7 Students are requested to contact the Academic Coordinator of Clinical Education as soon as possible if they have concerns regarding any aspect of the clinical placement, including issues with their own performance, their clinical instructor, other staff and clients.

11.1.8 The ACP is a University course evaluation document and its content is personal and hence confidential. The Clinical Education Site should not retain a copy of the completed document. It is the student’s decision and responsibility to provide a copy of the ACP to a potential reference.

11.1.9 The student should forward their completed Clinical Learning Contract, and Clinical Skills Checklist to the program upon completion of the clinical placement.

11.2 Evaluation of site:

11.2.1 Students evaluate their experience of the Clinical Education Site using the Student Evaluation of the Clinical Placement form on HSPnet.

11.2.2 The student should complete this form prior to midterm and final and discuss their feedback with their Clinical Instructor at that time.

11.2.3 Clinical education sites may make and keep a copy of this evaluation for their records.

Policy	International clinical placements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To describe the process and resources available to students participating in international clinical placements.

Policy statements

8.1 International clinical placements are opportunities which may be made available to students who have demonstrated excellence in their academic and clinical education work, a high level of self-directed learning and a history of embracing new opportunities within the Master of Physical Therapy program. International clinical placements can either be initiated by the student or may be facilitated by the Department of Physical Therapy (e.g. exchange programs, established Clinical Education Sites). There is no reimbursement of any costs related to clinical placements outside of Manitoba.

8.2 To be considered for this opportunity, students must:

8.2.1 Maintain a B+ average in their academic courses within the Master of Physical Therapy program.

8.2.2 Demonstrate excellence in clinical education as evidenced by their clinical education evaluations.

8.3 Students are not permitted to participate in international clinical placements in the first year of the program.

8.4 Students are required to initiate their request to complete an international clinical placement by approaching the Academic Coordinator of Clinical Education at least one year in advance.

8.5 Permission is given jointly by the Head of the Department of Physical Therapy, the Academic Coordinator of Clinical Education and the student’s Program Advisor. Permission is conditional upon the student maintaining the required level of academic and clinical education performance. Failure to do so will result in the student losing the opportunity to participate in the international clinical placement.

8.6 There is no reimbursement of any costs related to international clinical placements. Students must assume responsibility for all costs including:

8.6.1 Medical coverage

8.6.2 Visas

8.6.3 Accommodation

8.6.4 Travel

8.6.5 Any travel related vaccinations

8.6.6 Any additional required insurance coverage that is not routinely provided by the University

8.6.7 Phone calls, faxes, and postage to the Clinical Education Site.

8.7 For student-initiated clinical placements, students are responsible for checking in with the University’s International Centre via the Travel Tools page to identify potential travel restrictions before proceeding to make preliminary contact with prospective Clinical Education Sites to obtain written documentation as follows:

8.7.1 Description of the physical therapy service/program

8.7.2 Student Learning objectives

8.7.3 Evidence of professional organization accreditation or university approved status/affiliation.

8.8 The student must contact the local licensing body to determine if student licensure is required and the process involved.

8.9 The student must provide the Academic Coordinator of Clinical Education with copies of all correspondence between the student and the prospective Clinical Education Site.

8.10 The student must commit to the clinical placement once approval has been granted by the Master of Physical Therapy program.

8.11 A student who requests a clinical placement at a specific site that does not have a pre-existing legal agreement and affiliation with the University of Manitoba should be aware that a Clinical Education Site usually requires a contractual (legal) arrangement with the University of Manitoba prior to the student being permitted to commence their clinical placement. There is no guarantee that the University of Manitoba will be successful in establishing such a contractual arrangement with the new site, in which case the student should be prepared to select an alternate Clinical Education Site.

8.12 Students participating in international clinical placements must complete the following items on the University of Manitoba’s Travel Tools page :

8.12.1 The International travel registry at least 2 weeks prior to departure.

8.12.2 The pre-departure preparation courses provided on UMLearn (proof of completion to be sent to the Academic Coordinator of Clinical Education.

8.12.3 Sign and submit Informed Consent document, which is an Acknowledgement of Responsibility and Liability Waiver. This form outlines assumption of risk, assumption of responsibility and a liability while participating in international clinical placements.

8.12.4 Complete an emergency contact and medical information form prior to departure. This form will be kept on file in the office of the ACCE in case of an emergency during the clinical placement. At the end of the clinical placement, the form will be shredded. 

Policy	Insurance coverage
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline the liability and other insurance coverage that is in place to cover clinical education activities.

Policy statements

4.1 Students engaged in a clinical placement as a required part of their program are covered for liability under the University of Manitoba’s General Liability Insurance with the Canadian Universities Reciprocal Insurance Exchange (CURIE). Written documentation relating to the liability coverage is available in the form of a memo from the University of Manitoba administration.

4.1.1 Procedure: Anyone requiring a copy of this memo should contact the Academic Coordinator of Clinical Education.

4.2 Students engaged in a clinical placement in Manitoba as a required part of their program are covered for injuries sustained in the course of and arising out of the clinical placement under the Workers Compensation Act (Manitoba), in accordance with and subject to its provisions.

4.2.1 Procedure: In the event of a student being injured during a clinical placement, the Clinical Instructor or Clinical Education Site Leader should complete any necessary incident reports and promptly contact the Academic Coordinator of Clinical Education to ensure that coverage under the Workers Compensation Act is secured.

4.3 Students in the University of Manitoba Master of Physical Therapy program who are not Manitoba residents who engage in a clinical placement outside Manitoba may not be covered by the Workers Compensation Act (Manitoba). In this event, these students will be covered by an alternative policy through the University of Manitoba.

4.3.1 Procedure: On an annual basis, the Administrative Coordinator of Clinical Placements will inform the University of Manitoba Risk Management & Security Services of the number of non-Manitoban students who completed clinical placements outside of Manitoba during the last year.

4.4 International students in the University of Manitoba Master of Physical Therapy program who are attempting to arrange a clinical placement in their own country-of-origin may experience difficulties or be denied the clinical placement because the University is not able to guarantee that they will have workers compensation coverage during the clinical placement . Alternative arrangements can sometimes be made to cover these clinical placements, but this is done on a case-by-case basis. Students are encouraged to contact the Academic Coordinator of Clinical Education at the earliest opportunity to determine if any such alternative arrangements are possible.

Policy	Primary clinical instructor qualifications
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To provide guidelines regarding qualifications required of primary Clinical Instructors for students in the University of Manitoba Master of Physical Therapy program.

Policy statements

19.1 Primary clinical Instructors must be registered with their provincial (or relevant) regulatory body.

19.2 Completion of a Clinical Instructor Workshop is preferred but not required.

19.3 Completion of Clinical Instructor online training through the Universities of British Columbia or Western Ontario is preferred but not required.

19.4 Completion of a minimum of one year of post-licensure clinical experience.

19.4.1 Individuals with less than one full year of practice who have full registration with their regulatory college (i.e. who have passed the practical component of the Physiotherapy Competency Exam) may serve as primary clinical Instructors under the supervision of a more experienced Clinical Instructor. In this situation, the novice Clinical Instructor may contribute to the student evaluation, but the experienced Clinical Instructor will assume ultimate responsibility for guiding and evaluating the student on the clinical placement.

19.5 Physiotherapists who are currently under investigation, practice restriction or censure by the College of Physiotherapists of Manitoba must not supervise students on clinical placement for the duration of the investigation, practice restriction or censure. The College of Physiotherapists of Manitoba will inform the physiotherapist of this requirement at the commencement of the investigation, practice restriction or censure. Physiotherapists from other jurisdictions who are currently under investigation, practice restriction or censure by their regulatory college must not supervise students from the University of Manitoba program.

Policy	Professional appearance
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline expectations regarding professional appearance during clinical education activities which are considered appropriate according to current health care standards.

Policy statements

12.1 Guidelines

12.1.1 Dress code requirements may vary from site to site. Students must comply with the dress code of the particular Clinical Education Site at which they are completing their clinical placements. The following guidelines are based on the WRHA Dress Code Policy (#20.10.020) and serve as a general guide.

12.1.2 Clothing

12.1.2.1 Clothing and accessories should be clean, neat and of appropriate length, design, and fabric, and should not reveal underwear or the skin of the trunk, including with more active postures associated with therapeutic interventions.

12.1.2.2 “Business casual” attire is the generally accepted style for clinical placements unless otherwise directed by the Clinical Education Site. Jeans, shorts and risqué outfits are not considered appropriate apparel.

12.1.2.3 Clothing shall not display offensive language, logos, or images.

 

12.1.3 Footwear

12.1.3.1 Footwear should be clean, meet safety requirements of the work area and provide for safe mobility.

12.1.4 Jewellery

12.1.4.1 Jewelry should not interfere with the practice of routine precautions or present surfaces that could result in injury to client or self.

12.1.5 Personal Hygiene

12.1.5.1 Good personal hygiene and cleanliness shall be practiced.

12.1.5.2 Hair should be clean and not able to fall where it may contact clients and other surfaces.

12.1.5.3 Nails should be clean and short. Artificial fingernails, gel nails, or extenders shall not be worn.

12.1.6 Scented Products

12.1.6.1 Fragrances and other scented products should not be used/worn by students on clinical placement.

12.1.7 Headphones

12.1.7.1 The wearing of headphones/ear plugs in conjunction with personal electronic devices is not permitted during clinical placement hours.

12.1.8 Nametags

12.1.8.1 University of Manitoba nametags must be worn at all times during clinical placements.

12.1.8.2 One nametag is ordered for each student at the beginning of the Master of Physical Therapy program. If a student loses their nametag, they should inform the Academic Coordinator of Clinical Education immediately so that a replacement nametag can be ordered. Students are responsible for the cost of their initial nametag and any replacements.

12.1.8.3 Students may also be supplied with an identification badge by their Clinical Education Site. Students are expected to also wear this badge in compliance with the policies of the Clinical Education Site. These nametags must be returned to the Clinical Education Site at the end of the clinical placement.

Policy	Professional behaviour
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline expectations relating to professional behavior during clinical placements.

Policy statements

13.1  Ethics:

13.1.1 Each student should review and adhere to the Codes of Ethics of the College of Physiotherapists of Manitoba, Canadian Physiotherapy Association and the University of Manitoba during clinical placements.

13.1.2 Students on clinical placement outside Manitoba should review and adhere to the appropriate provincial/national code of ethics that pertains to the geographic area in which they are situated.

13.1.3 Students are expected to follow the policies and procedures of their Clinical Education Site for the period of the clinical placement.

13.1.4 Clinical Education Site policies concerning the acceptance of gifts from clients will apply to students completing clinical placements at the site.

13.2 Title:

13.2.1 Students must only use the title "Student Physical Therapist" or “Student Physiotherapist" to clearly identify their student status. This title is to be used on a nametag, in documentation, on written projects, etc.

13.3 Professional Behaviour:

13.3.1 Students are expected to comply with any provincial legislation which directs professional behaviour (e.g. Mental Health Act, Protection of Persons in Care Act, Vulnerable Persons Act, etc.)

13.4 Representation:

13.4.1 Students are considered representatives of the physical therapy profession and the University of Manitoba and should behave accordingly.

13.5 Confidentiality:

13.5.1 It is essential that students maintain confidentiality in all matters related to clients. This is important both in oral communication with/about clients and in the handling of written communication such as charts.

 

13.5.2 Students are legally responsible to follow any provincial legislation that pertains to confidentiality of clients (e.g. the Personal Health Information Act [PHIA]). Students who are completing clinical placements in other provinces or countries are responsible for determining the name and specific requirements of the appropriate local legislation and adhering to the law.

13.6 Documentation:

13.6.1 Documentation or notes which are written by students should be signed by the student in the following manner: Student Name (Student Physical Therapist or Student Physiotherapist).

13.6.2 Students are required to familiarize themselves with the charting/documentation requirements of their Clinical Education Site and to adhere to those policies and/or guidelines.

13.6.3 Some Clinical Education Sites may require a student to attend a documentation training session prior to their clinical placement. Students are expected to arrange to attend this scheduled orientation.

Policy	Support, communication and monitoring processes during clinical placements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To identify roles and responsibilities of physical therapy faculty who support the teaching/learning experience during clinical placements and serve as a resource by monitoring the clinical education experience and representing the University of Manitoba, Department of Physical Therapy.

Policy statements

17.1 The Academic Coordinator of Clinical Education will provide guidance, support, facilitation and mediation to students, Clinical Instructors and Program Advisors to facilitate successful clinical placements for students.

17.2 Students and Clinical Instructors may contact the Academic Coordinator of Clinical Education at any time throughout a clinical placement regarding any clinical placement matter.

17.3 In the event of problems with student performance, both the student and Clinical Instructor must inform the Academic Coordinator of Clinical Education as early as possible.

17.4 Students in the Master of Physical Therapy program are assigned a Program Advisor who follows their progress through both the academic and clinical components of the program. The Program Advisor should contact their students at the placement midterm to check on their progress and how they are managing generally. Students may contact their Program Advisor to discuss their progress at any time during the clinical placement. Program Advisors may advise the student but should also inform the Academic Coordinator of Clinical Education as soon as possible if there are any issues requiring intervention.

Policy	Student certification requirements
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline the documentation and certifications required of students prior to their involvement in clinical education activities.

Policy statements

5.1 Successful applicants who accept an offer of admission to the Master of Physical Therapy program must submit the following documentation to the Administrative Coordinator of Clinical Placements in accordance with the issue dates and deadlines provided with their offer of admission. These documents are required in order for students to engage in clinical education activities once the program commences.

5.1.1 Completed Health Questionnaire, Immunization Status/Record and MIMS Release of Information Form

5.1.2 Current Basic Life Support (BLS) for Healthcare Provider (C) certification (or higher) provided by an instructor certified through the Heart & Stroke Foundation.

5.1.3 Criminal Record Check including a vulnerable persons’ screen

5.1.4 Child Abuse Registry Check

5.1.5 Adult Abuse Registry Check

5.1.6 Membership card or receipt verifying current registration with the College of Physiotherapists of Manitoba

5.2 Students are required to complete “Mask Fit Testing” using the mask designated by the Master of Physical Therapy program. Students may have the opportunity to complete this testing through the Master of Physical Therapy program but will be responsible for the cost of testing. Students should refer to relevant information included with the offer of admission. Certification must remain current during all clinical placements.

5.3 Students must attend the Personal Health Information Act Session and must be able to present proof of attendance (PHIA Card) at their Clinical Education Sites prior to beginning their clinical placements.

5.4 Students must attend the WRHA Routine Practices session and must be able to present a completed checklist indicating demonstration of effective infection prevention and control procedures.

5.5 Returning students are required to annually:

5.5.1 Review and update immunization(s) as necessary. Annual physical and dental examinations are recommended.

5.5.2 Acquire re-certification in Basic Rescuer Cardio Pulmonary Resuscitation through a course provided by a Heart and Stroke certified instructor. Documentation of this recertification must be provided to the Academic Coordinator of Clinical Education by the date published yearly in information provided to students.

5.5.3 Register as a student member with the College of Physiotherapists of Manitoba.

5.5.4 Complete a Criminal Records Check (including a vulnerable persons’ screen), Child and Adult Abuse registry checks. Documentation of the results of these tests must be provided to the Administrative Coordinator of Clinical Placements by the date published annually in information provided to students.

5.5.4.1 Students with a positive Criminal Record, Child or Adult Abuse Registry Check will be asked to provide details to the Head, Department of Physical Therapy (or designate).

5.6 It is the student's responsibility to ensure that all of the foregoing information/documentation is acquired. The student is also responsible for payment of all costs incurred by this process.

5.7 Health Forms will be kept in the student file in a secure location within the Rady Faculty of Health Sciences Immune Status Program.

5.8 Confirmation of completion of all other requirements by each student (e.g. copies of these documents) will be held securely within the College of Rehabilitation Sciences offices.

5.9 Students are required to maintain and present original copies of all required documents as determined by their assigned Clinical Education Sites.

5.10 Clinical Education Sites may require other conditions to be met by students prior to starting a clinical placement. Students are responsible for meeting these requirements and for any related costs.

Policy	Required mix of clinical education experiences for each student
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To outline the mix of clinical placement experiences (clinical areas, settings, and patient age groups) required by students to prepare them as effective graduate physiotherapists and for the program to meet accreditation standards (Physiotherapy Education Accreditation Canada Accreditation Standards, 2012, rev. 2017.).

During their time in the University of Manitoba Master of Physical Therapy program, each student will be allocated a set of clinical placements that ensures they receive the following clinical education experiences:

2.1 Each student shall complete a minimum of 1,025 hours of physiotherapy clinical placements.

2.2 Each student shall complete a minimum of 100 hours involving direct clinical care of patients in each of the following essential areas of practice:

2.2.1 Cardiovascular and Pulmonary conditions

2.2.2 Neurological conditions

2.2.3 Musculoskeletal conditions. (All students must complete a minimum of one outpatient orthopedic clinical placement.)

2.3 Each student shall complete a minimum of 100 hours of clinical experience in each of the following essential settings:

2.3.1 Acute Care

2.3.2 Rehabilitation/Long term Care

2.3.3 Ambulatory Care

2.4 While on clinical placement in the above areas, each student will gain significant clinical experience working with:

2.4.1 Patients with multisystem conditions

2.4.2 Patients from at least two of the following three age groups:

2.4.2.1 Pediatric (0-17 years)

2.4.2.2 Adult (18-64 years)

2.4.2.3 Older adult (65 years and older)

2.5 In addition, many students will have the opportunity to experience a non-traditional model clinical placement, including:

2.5.1 Multiple students to one Clinical Instructor

2.5.2 Multiple Clinical Instructors to one student

2.5.3 Senior-junior student pairing with one Clinical Instructor

2.5.4 Student-led clinics in neuro, manual therapy, and sports

2.5.5 Emerging role placements in primary care and cancer care

2.5.6 Interprofessional collaborative placements

2.5.7 Rural placements including Northern/remote/Indigenous communities

2.5.8 Research placements

Policy	Use of social media
Approved by	Clinical Education Committee
Approval date	November 29, 2018

Purpose

To provide students in the Master of Physical Therapy program with guidance regarding safe and professional use of social media, respecting legal, ethical and regulatory requirements of the profession, University and College of Physiotherapists of Manitoba.

Policy statements

The following statements are based on the College of Physiotherapists of Manitoba Guideline: Use of Social Media (Jan 26, 2017).

22.1 Students should assume that all content on the Internet is public and accessible to all, including professional contacts, colleagues, clients/patients, and employers.

22.2 Students must not post information on-line that relates to an actual client/patient. They must ensure compliance with legal and professional obligations to maintain privacy and confidentiality and be aware that an unnamed client/patient may still be identified through a range of other information, such as a description of their clinical condition or area of residence.

22.3 Students must refrain from providing clinical advice to specific clients/patients through social media.

22.4 Students must protect their own reputation, the reputation of the profession and the University, and the public trust by not posting content that could be viewed as unprofessional.

22.5 Students are expected to be mindful of their internet presence and be proactive in removing content posted by self or others which may be viewed as unprofessional. Students are reminded that when they self-identify as a physiotherapist, they are using title and are subject to the standards of the College of Physiotherapists of Manitoba, even on personal accounts. Students must refrain from establishing personal connections with clients/patients or persons closely associated with them on-line, as this may hinder their maintenance of appropriate professional boundaries and compromise their objectivity.

22.6 Students must refrain from seeking out client/patient information that may be available on-line without prior consent, as individuals are entitled to a reasonable expectation of privacy. While students are expected to adhere to all of their relevant legal obligations under PHIA with respect to the collection of personal health information, they should also refrain from seeking out other types of non-protected information on-line without prior consent.

22.7 Students must read, understand, and apply the strictest privacy settings necessary to maintain control over access to their own personal information.

22.8 Students must comply with relevant Clinical Education Site policies regarding social media usage and general policies on computer and internet usage.

22.9 Students should recognize that social media platforms are constantly evolving and be proactive in considering how professional expectations apply in any given set of circumstances.

Item	Date
Approved CoRS	May 2020
Approved Senate Committee on Instruction and Evaluation	Oct 2020
Approved Senate	Nov 2020

All University regulations apply to all students in the program which include General Academic Regulations, University Policies and College of Rehabilitation Sciences Academic Regulations.

The Bachelor of Respiratory Therapy program (the “Program”) will use the following regulations outlined below to guide progression issues in all years of the Program. Students are obligated to be familiar with all regulations governing their continued progress in the Program.

Security of Academic Records

The University’s policies regarding the security of student academic records are found in the General Academic Regulations.

Registration Status in the Program

Students are required to register for a full course load for all three years of the Program. Any consideration of part-time or out of sync status shall be reviewed by the year coordinator in collaboration with the Department Head, Respiratory Therapy, on a case-by-case basis.

Transfer of Credit

Students are required to submit a formal letter and supporting documentation such as course outlines to the Department Head at least 30 days prior to the course start date for transfer of credit. Courses will be evaluated in conjunction with the applicable course coordinator to review the request within 10 working days of received documentation.

Academic Progression

Due to the integrated nature of the Program curriculum, students are generally required to complete all courses in one term in order to progress to subsequent terms. Similarly, successful completion of each year is required to progress to subsequent years of the Program.

Students are required to obtain a minimum of “C” grade in every letter grade course and a “Pass” in every Pass/Fail course. A final grade of “D” or “F” in a letter grade course or “Fail” in a Pass/Fail course taken to complete the degree requirement is considered a failure.

Dean’s Honour List

Students carrying a full course load, with a sessional Grade Point Average of 3.7 or higher and have not done re-sit or supplemental exams, are placed on the Dean’s Honour List.

Academic Remediation and Probation

If a student is having difficulties academically as seen in failures in course assessments (less than a grade of ‘C’ or 62%) within the term, a remediation plan will be developed by the student year coordinator in collaboration with the student to promote success.

If a student fails a course or if their term GPA drops below 2.5 they will be placed on Academic Probation for the following term.

A formal remediation plan will be mandatory for students on academic probation.

The remediation plan will be developed by the department head or designate.

The remediation plan will be based on an assessment of the student’s current academic status and identified learning needs.

The student may be required to repeat or audit selected Program courses.

If any courses are repeated, the student will be subject to all academic regulations related to final grades in repeated courses and the number of failures allowed in any given course or sequence of courses in the Program.

The student will be required to meet with a year coordinator at least twice during the following term of study.

If there are non-academic issues interfering with the student’s academic progress, the student will be required to make every effort to deal with and resolve those issues during the period of academic probation.

When indicated, a student will be referred to the student services unit for information and guidance. Similarly, students requiring accommodation will be referred to Student Accessibility Services. When Student Accessibility Services identifies a non-standard accommodation, the College of Rehabilitation Science Accommodations Team will be consulted.

If a student is unsuccessful in a course while on academic probation, they will be required to withdraw from the Program.

Supplemental Examinations or Tests

A student who fails (obtains less than “C”) in one course may be granted supplemental privileges. The composition of the supplemental examination will be determined by the course coordinator, which will adjudicate each case individually after receiving a written recommendation from the Head of the Department.

The passing grade in a supplemental examination will be a “C+”.
A student may not write more than two (2) supplemental examinations per year. If the student should fail (obtaining less than C+), the student may be granted the privilege of repeating the courses in the following academic year and will be reviewed at the BRT progression committee on a case by case basis. Subsequently, the student may proceed to repeat the year on a part time basis but may be required to audit courses as deemed appropriate due to the integrated nature of the BRT curriculum.

A student may not progress to subsequent years of the Program with any failures.

Clinical Courses

If a student fails a clinical course, they are permitted to repeat the course.

If the student fails a second clinical course in the Program, they are permitted to repeat the course and will be placed on Academic Probation. Any further unsuccessful attempts in clinical courses will require the student to withdraw from the Program.

Professional Behavior

A student may be debarred from class, laboratories, and examinations by action of the department head for persistent non-attendance, failure to produce assignments to the satisfaction of the instructor, and/or unsafe clinical practice or practicum. Students so debarred will have failed that course.

Once the debarment process has been initiated, the student will not be able to voluntarily withdraw from the course that is presently under investigation. Students so debarred will have failed that course.

As an entry to practice professional degree Program, there are Program expectations designed to ensure that students in the Program are developing the competencies and accountability standards that reflect the public expectation of practicing professionals in the field. As such, students are expected to take responsibility for their learning, and to adhere to the policies of attendance and participation related to classes and fieldwork placements.

Any student who demonstrates behavior with respect to other students, colleagues, faculty, clients or the general public that is exploitative, irresponsible, destructive or unsafe in connection with any work engaged in while enrolled in the Program will be subject to discipline as described in the University of Manitoba Student Discipline By-Law.

Voluntary Withdrawal and Repeated Course

Students are permitted to voluntarily withdraw from a Program course in accordance with the University Voluntary Withdrawal Policy.

Students who have elected to voluntarily withdraw are not permitted to enroll in any further courses in the Program without approval from the department head. The student may be permitted to repeat the course after consultation with year coordinator and department head and the development of an individualized program plan.

Students planning to withdraw from any course are advised to speak with the department head regarding the implications of this decision. Withdrawal from a course or courses may affect academic progression, financial aid eligibility, entrance into other programs, and/or student visa requirements. Any implications will be the responsibility of the student.

Attendance

Regular attendance is expected of all students in all courses. Prior permission is required for any anticipated absences. Students absent from class due to illness may be required to present a certificate from a physician. Unexcused absence from an examination may result in a grade of zero for that examination. Make-up examinations may be allowed under special circumstances.

Attendance in the clinical practice/laboratory portions of Program courses is mandatory and tracked, to enable the student to satisfy the evaluative criteria of the theoretical and practical components of courses and to meet the mandatory hours requirements. Should a student meet or exceed the permissible number of absences, an attendance plan to make up the absences is

required. Failure to make up the absences via the attendance plan may result in failure of the course.

Academic Integrity

Plagiarism or any other form of cheating in examinations, term tests or academic work is subject to serious academic penalty in accordance with University of Manitoba Student Discipline By- Law.

Clinical Placement and Practice

The third and final year of the Program is comprised almost entirely of clinical courses. All students must be registered in all clinical courses for both terms by the specified deadline.

Students may be required to complete clinical placements outside of Winnipeg in any year during the Program. There may be affordable short term housing options in some locations, which students may utilize. Costs associated with the approved facility based housing options, may be subsidized by the University of Manitoba. The student may be required to assume full or partial costs associated with clinical education placement.

The following health requirements are mandatory upon acceptance to the Program, and may require annual renewal during the Program:

Personal Health Information Act (PHIA) Training

PHIA cards are required for clinical placement and practice, and may be checked at clinical education sites.

Electronic Patient Record Training

The requirements to allow students to be provided EPR access will be facilitated by the clinical education coordinator. Students must complete a training seminar.

Immunizations

Standard Health Record Form Packages are sent to new students in Respiratory Therapy upon acceptance into the program. New students in Respiratory Therapy are required to return forms to their department by the dates published yearly in the Health Record Form Packages. Returning students are required annually to review and update immunizations as necessary.

Students who do not comply with the deadlines for completion of their immunizations, may be prohibited from registering which may prevent receipt of refunds, histories/transcripts from the Registrar’s Office, attending clinical placements, and graduation.

Mandatory Annual Influenza Vaccination

All students enrolled in the Program are required to obtain an annual influenza vaccination and provide verification documentation by the published deadline, unless otherwise advised by a physician in writing. Students who fail to provide documentation of flu vaccination by the published deadline, will not be permitted to participate in any Program clinical courses.

Criminal Record, Vulnerable Persons, Adult/Child Abuse Registry Check
All respiratory therapy students are required to obtain a formal Criminal Record and Vulnerable Persons Check, an Adult Abuse Registry Check, and a formal Child Abuse Registry Check by the first day of classes of each year of the program. These records must have been issued within the ninety (90) days previous to that date to ensure that they remain current until the end of the clinical education period for each year of the program. These documents are required for participation in all clinical/fieldwork education activities.

If student documentation reveals a criminal charge or conviction, the Respiratory Therapy Progression Committee will review which may result in dismissal from the program.

Cardiopulmonary Resuscitation Certification (CPR)

All students (both new and returning) in the Department of Respiratory Therapy are required to obtain Heart and Stroke Foundation of Canada certification in cardiopulmonary resuscitation annually. Certification must be at the Basic Life Support (BLS) for Healthcare Providers.

Students in year 1 and 2 of the program will be required to provide proof of certification by the first day of class. Students in year 3 of the program will be required to provide proof of certification before the first day of their fieldwork placement. For students in all years of the program, proof of certification must not have an issue date prior to the last week in June of the current year. This will ensure that the certification remains current until the end of the clinical education period for each year in the program

Students who do not comply with the deadlines for completion of CPR training, may be prohibited from registering which may prevent receipt of refunds, histories/transcripts from the Registrar’s Office, attending clinical placements, and graduation.

N95 Mask Fit Testing

Clinical/fieldwork education sites require Respiratory Therapy students to maintain mask fit certification. Information on acquiring this certification is provided to new students with the Health Record Form Packages. All students are required to maintain mask fit certification throughout the program in accordance with the Program’s Mask Fit Test policy.

Unsafe Clinical Practice

A student may be disbarred if they are reported to have demonstrated unsafe clinical practice. Unsafe clinical practice involves actions or behaviors that result in adverse effects or the risk of adverse effects to the health and well-being (psychological or physical) of the patient, family, staff, faculty, or other students. Unsafe clinical practice is an occurrence, or a pattern of behavior involving unacceptable risk.

Appeals

Students may appeal term work grades, final grades and other appeals in accordance with the College of Rehabilitation Sciences Undergraduate Student Appeals Policy and University Examination Regulations.

Time Limit
The Program must be completed in five years.

Adapted and revised from College of Nursing, Rady Faculty of Health Sciences, University of Manitoba

Category	Details
Procedure	Undergraduate student academic appeals
Parent policy	Student academic appeals policy
Effective date	March 21, 2016
Revised date	August 28, 2023
Review date	June 30, 2028
Approving body	College of rehabilitation sciences council, Faculty of Rady faculty of health sciences council
Authority	College of rehabilitation sciences council
Responsible executive officer	Dean, College of rehabilitation sciences
Delegate
Contact	Chair, undergraduate student academic appeals committee
Application	College council; students; academic staff

 Reason for policy

1.1. The Undergraduate Student Academic Appeals Policy (the “Policy”) and related Procedures (the “Procedures”) provide guidance to College of Rehabilitation Sciences’ members charged with determining appeals of an academic nature upon application by an Appellant. Applications for appeal include, but are not limited to: appeals of term work, final grades, final and term work program requirements, deferred exams, authorized withdrawals, retroactive voluntary withdrawals, academic status, or appeals of other academic decisions made in reference to undergraduate students within the College of Rehabilitation Sciences.

1.2. The Policy and related Procedures also provide guidance to Appellants and their right of appeal to the Student Academic Appeals Committee (SAAC).

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2. Policy

2.1.  Definitions:

• 2.1.1.  Appeal – an appeal is an examination by an official body of a decision made at a lower level of authority. In the university context, academic appeals focus mainly on scrutiny of the evaluation/grading process in order to determine if a procedural error or omission has occurred in the Appellant’s (student’s) case. Student appeals are initiated by the student.
• 2.1.2. Hearing – appeal hearings are conducted by the Undergraduate Student Academic Appeals Committee, a standing committee within the College of Rehabilitation Sciences, Rady Faculty of Health Sciences. A hearing provides the student with a mechanism to challenge an academic decision on procedural grounds, beyond the individual course coordinator or the Department Head.
• 2.1.3.  Appellant – the student appealing a decision affecting the student’s own academic standing or receipt of awards, within the College of Rehabilitation Sciences
• 2.1.4. Chair – the Chair of the Undergraduate Student Academic Appeals Committee
• 2.1.5. Committee – the Undergraduate Student Academic Appeals Committee
• 2.1.6. Members – members of the Undergraduate Student Academic Appeals Committee convened for the purpose of:
  • 2.1.6.1. Determining its jurisdiction;
  • 2.1.6.2. Determining the Appellant’s standing and whether there are grounds of appeal;
  • 2.1.6.3. Hearing appeals.
• 2.1.7. Respondent – a representative or representatives of the College of Rehabilitation Sciences designated by the Dean/Designate to represent the College in relation to an appeal.

2.2. Undergraduate Student Academic Appeals Committee: There shall be a College Student Academic Appeals Committee that:

• 2.2.1. Receives and considers requests from students with regard to appeals of academic decisions made by individual faculty/instructors, Department Student Progress Committee(s) or College Council on behalf of the College of Rehabilitation Sciences.
• 2.2.2. Hears academic appeals which concern: grade(s), final and term work program requirements, outcomes of term work or final grade appeals initiated through the Registrar’s Office, deferred exams, authorized withdrawals, retroactive voluntary withdrawals, academic status, or appeals of other academic decisions.
• 2.2.3. Makes decisions on appealable matters that shall be final and binding within the College.
• 2.2.4. Informs the Dean/Designate of the results of all appeals submitted to it.
• 2.2.5. Reviews the Student Academic Appeals Policy and related Procedures periodically and, if necessary, recommends changes to College of Rehabilitation Sciences Council.
• 2.2.6. Prepares and submits an annual report for presentation to the College of Rehabilitation Sciences College Council.

2.3. The grounds for an appeal to be heard by the Committee shall include:

• 2.3.1. Failure of the Program/Department/Faculty Members or Dean to follow procedures.
• 2.3.2. Failure of the Program/Department/Faculty Members or Dean to follow the rules of natural justice.
• 2.3.3. Failure of the Program/Department/Faculty Members or Dean to reasonably consider all factors relevant to the decision being appealed.
• 2.3.4. There is evidence that a College/Department regulation has been unfairly applied.
• 2.3.5. The regulation itself seems to impose undue hardship on an individual in the College or has become inapplicable through lapse of time or changes made.
• 2.3.6. There is apparent conflict between Senate policy and a Rehabilitation Sciences College Council decision.
• 2.3.7. There are conflicting interpretations of a College regulation.
• 2.3.8. Other circumstances that seem to warrant special consideration.

2.4. The Committee shall hear an appeal by an Appellant against a decision by a Program/Department/Faculty Member affecting the academic progress, or the receipt of an award, only after all reasonable avenues of informal appeal have been exhausted.

2.5. Committee Terms of Reference for the Undergraduate Student Academic Appeals Committee are established and outline the Committee function, composition, terms of office, quorum, and meetings (refer to SAAC TOR March 2016).

• 2.5.1.Where possible, the composition of the Committee shall maintain an equitable diversity balance.
• 2.5.2. Vacancies on the Committee shall be filled by the original bodies that made the appointment or conducted the election.
• 2.5.3. Faculty members sitting on the Undergraduate Student Academic Appeals Committee who are directly involved in an appeal being heard shall be replaced by a designate appointed by the Dean (or designate), College of Rehabilitation Sciences, for the duration of that particular appeal. Student members of the Committee who are directly involved in an appeal being heard shall be replaced by a designate appointed by the College of Rehabilitation Sciences Student Council President for the duration of that particular appeal.
• 2.5.4. If the Chair of the Committee is unable to sit for any reason, another member of the committee shall be appointed by the Chair as an acting Chair.

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3. Accountability

3.1.  The Dean of the College of Rehabilitation Sciences is responsible for advising the Chair of the Student Academic Appeals Committee that a formal review of this Policy is required.

3.2. The Dean or Designate is responsible for the implementation, administration and review of this Policy.

3.3. The College of Rehabilitation Sciences College Council, academic staff and students are responsible for complying with this Policy.

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4. Policy review

4.1. Governing document reviews shall be conducted every five (5) years. The next scheduled review date for this Policy is June 28, 2028.

• 4.1.1. In the interim, this Policy may be revised or repealed if
  • 4.1.1.1. Senate or approving body deem necessary or desirable to do so; or
  • 4.1.1.2. The relevant governing documents are revised or rescinded.
• 4.1.2. If this Policy is revised or repealed, all secondary documents will be reviewed as soon as reasonably possible in order to ensure that they:
  • 4.1.2.1.    Comply with the revised Policy; or
  • 4.1.2.2.    Are in turn repealed.

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5.    Cross references

5.1. This policy should be cross-referenced to the following relevant governing documents, legislation and/or forms:

• 5.1.1. College of Rehabilitation Sciences Undergraduate Student Academic Appeals Procedures
• 5.1.2. College of Rehabilitation Sciences Undergraduate Student Academic Appeals Committee Terms of Reference
• 5.1.3. College of Rehabilitation Sciences Undergraduate Student Academic Appeal Form
• 5.1.4. University of Manitoba Student Appeals Policy
• 5.1.5. University of Manitoba Senate Committee on Academic Appeals

Procedure	Undergraduate Student Academic Appeals
Parent policy	Undergraduate Student Academic Appeals Policy
Effective date	March 21, 2016
Revised date	August 28, 2023
Review date	June 30, 2028
Approving body	College of Rehabilitation Sciences Rady Faculty of Health Sciences
Authority	College of Rehabilitation Sciences Council
Responsible executive officer	Dean, College of Rehabilitation Sciences
Delegate
Contact	Chair, Undergraduate Student Academic Appeals Committee
Application	College Council; Students; Academic Staff

Part I Reason for procedure

1.1. To set out Procedures secondary to the Policy entitled “Undergraduate Student Academic Appeals” in order to establish a process for appeals to be heard, and to provide guidance to the members of the Undergraduate Student Academic Appeals Committee, the student, and the College representatives in relation to appeal hearings.

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Part II Procedural content

2. General

2.1. The Rehabilitation Sciences College Council, in approving these Procedures, wishes to impress upon the parties appearing before the Committee that the appeal hearing is intended to be a review of the facts which bear on the issues before the Committee. Questions by the Committee members to the Appellant and to the Respondent during the course of the appeal hearing should be expected. Nothing in these Procedures should be taken, however, as relieving the Appellant of the responsibility of making a submission and presenting evidence in support of his/her appeal.

2.2. Prior to submitting an appeal to the Committee, the Appellant must have exhausted all procedures and appeal processes available to him/her at the Course Coordinator/Department level and/or the Registrar’s Office (grade appeal).

2.3. Appeals involving a specific course should be formally initiated through the Department providing the course, while appeals relating to a program should be initiated through the College responsible for the program.

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3. Processes for the appeal of Term Work

3.1. Students desiring to discuss matters relating to marks assigned to term work should discuss the matter with the Course Coordinator/Instructor in the first instance.

3.2. If the student is unsatisfied with the decision of the Course Coordinator/Instructor, then the student may make a formal appeal through the University of Manitoba Registrar’s Office in accordance with the regulations and deadlines to file an appeal as posted on the Registrar’s Office website. The following are links to the information webpage and the Appeal Form required for Appeal of Term Work.

• 3.2.1. Note that an appeal of term work must be made within ten (10) days of receiving the Term Work grade.
• 3.2.2. Information page
• 3.2.3. Appeal form

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4. Processes for the appeal of Final Grades

4.1. If a student has good reason to believe a mistake has been made in the assessment of the original grade, an appeal of the assigned grade may be made.

4.2. In the first instance, students desiring to discuss matters relating to final grades should discuss the matter with the Course Coordinator/Instructor.

4.3. If, following an informal appeal to the Course Coordinator/Instructor, the student is unsatisfied with the decision of the Course Coordinator/Instructor, then the student may make a formal appeal through the University of Manitoba Registrar’s Office in accordance with the regulations and deadlines to file an appeal as posted on the Registrar’s Office website. On payment of the prescribed fee, such appeals will be forwarded to the Head of the Department in which the course is offered.

4.4. Final examination scripts are to be held by the teaching unit responsible for the course until six months after the expiration of the appeal period. In individual cases where appeals have been initiated, the holding period will be extended accordingly. Any projects of work submitted for marking and whose mark will comprise part of the final grade without the student being informed of the resulting mark on that particular item, shall be retained until expiration of the appeal period.

4.5. Teaching units shall be responsible for destroying examination scripts held by them in accordance with these procedures, ensuring in the process of confidentiality of the documents.

4.6. Students whose grades are reassessed as the result of an appeal initiated through the Registrar’s Office may subsequently appeal to the CoRS Undergraduate Student Academic Appeals Committee.

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5. Filing an appeal with the College of Rehabilitation Sciences Undergraduate Student Academic Appeals Committee

5.1. A Student may file an appeal, along with all relevant documentation, with the Dean of the College of Rehabilitation Sciences within 10 working days following notification of:

• a) a decision by a Department Head regarding an appeal of one or more marks assigned to term work;
• b) a College Council decision of an academic nature that directly affects the student; or
• c) the outcome of an appeal of one or more final grades that was initiated through the Registrar’s Office.

5.2. If an Appellant files an appeal beyond the ten (10) working days period, the Appellant must provide written reasons for the delay. The Chair shall have the discretion to extend the deadline for filing an appeal if it is determined that there are special circumstances which justify or excuse the delay. The Chair’s decision is final and not appealable.

5.3. The Appellant must submit all documentation that will be relied on for the appeal and must include the following:

• a) a completed and signed Student Appeals Form which is available at the main office of the College of Rehabilitation Sciences or on the College of Rehabilitation Sciences website;
• b) a letter to the Chair clearly explaining the grounds for the appeal, with specific reference to section 2.3 of the Undergraduate Student Academic Appeals Policy (re: grounds for appeal);
• c) a copy of the letter of decision from the last appeal level (if applicable);
• d) a copy of all documentation submitted to the last appeal level (if applicable);
• e) the names of any witnesses, recognizing that calling them is at the discretion of the Chair;
• f) the remedy sought of the Committee; note that this should not differ from that requested at the last appeal level unless extraordinary circumstances are presented;
• g) the name of any spokesperson.

All submitted documents are considered confidential and will be subject to the provisions of The Freedom of Information and the Protection of Privacy Act and The Personal Health Information Act.

5.4. The Appellant shall have the right to be accompanied by a spokesperson:

• This spokesperson/representative may be from the Student Advocate’s Office or a representative from the University of Manitoba Students’ Union, a member of the university community not receiving payment for appearing, a member of the Appellant’s immediate family, or a lawyer.
• It is the Appellant’s sole responsibility to:
  • Ensure that the spokesperson is familiar with the Undergraduate Student Academic Appeals Policy and Procedures
  • Ensure the adequacy of his/her representation
    - Pay for his/her own lawyer’s fees, if any.

5.5. The Dean/Designate shall forward copies of the written appeal to the Chair of the Student Undergraduate Academic Appeals Committee and the Head of the appropriate Department.

5.6. The Chair of the Undergraduate Student Academic Appeals Committee shall inform the members of the Committee of the nature of the appeal, call a meeting to determine jurisdiction; whether the Appellant has standing, whether there are sufficient grounds for the appeal. The Chair, at his/her discretion, may invite the parties to make submissions on the question of jurisdiction or standing. The Chair shall direct the Committee that, in its consideration, the benefit of the doubt will always be given to the Appellant:

• a) If the Committee determines that there is no jurisdiction to hear the appeal, and/or the Appellant has no standing, and/or there are insufficient grounds to consider an appeal, the file shall be closed, the appeal will be deemed dismissed and the Appellant, and the Respondent will be informed by letter (subsection 6.7(a) of these Procedures);
• b) If the Committee determines that there is jurisdiction to hear the appeal, the Appellant has standing, and there are sufficient grounds, the Chair Shall:
  • i. inform the Appellant in writing of the date and reason for the hearing;
  • ii. inform the Appellant of Committee membership, along with a deadline to submit concerns regarding perceived conflicts;
  • iii. inform the Dean/Designate of the date of the hearing;
    iv.Notify the appropriate College Council members involved, herein named the “Respondent”, of the date of the appeal hearing;
  • v.Request that the Respondent provide a written response to the appeal. At least seven (7) working days must be allowed in which to provide this written response back to the Chair.

5.7. If a Respondent requests an extension beyond the seven (7) working days, they must provide written reasons for the delay. The Chair shall have the discretion to extend the deadline for filing a response if it is determined that there are special circumstances which justify or excuse the delay. The Chair’s decision is final and not appealable. If the deadline is not met, the appeal will proceed without the Respondent’s written submission.

5.8.The Respondent must submit all documents that will be relied on for the appeal and must include the following:

• a) a letter to the Chair clearly outlining the response to the appeal;
• b) a copy of the appeal documentation submitted by the Appellant to the last appeal level, unless already submitted by the Appellant (if applicable);
• c) a copy of the documentation the Respondent relied upon to make his/her decision at the last appeal level (no new documentation can be submitted at this time) (if applicable);
• d) information on witnesses/members of the College who will accompany and assist the Respondent at the hearing. Recognize that calling witnesses is at the discretion of the Chair (see subsection 5.3 (e) of these Procedures).

All submitted documents are considered confidential and will be subject to the provisions of The Freedom of Information and the Protection of Privacy Act and The Personal Health Information Act.

5.9. The Chair shall provide the Appellant with copies of the written response by the Respondent prior to the date of the hearing.

5.10. Appellants must provide a written response addressing any perceived conflicts with Committee membership, stating reasons, prior to the deadline established by the Chair.

5.11. All members of the Undergraduate Student Academic Appeals Committee will be provided with the Undergraduate Student Academic Appeals Policy and Procedures documents.

5.12. In the cases of absence of members or possible conflicts of interest relative to any members of the Undergraduate Student Academic Appeals Committee, the Dean/Chair shall appoint an alternate for the duration of the appeal (see sections 2.5.3 and 2.5.4 of the Undergraduate Student Academic Appeals Policy).

5.13. In the event that the Chair appoints an alternate to the Committee, it should be assured that the resultant Committee composition does not give rise to perceived bias and follows, where possible, the membership composition (Section 3 Undergraduate Student Academic Appeals Committee Terms of Reference).

5.14. Committee members (faculty, students or Chair) shall be disqualified from the hearing who:

• a) are directly involved in the circumstances of the appeal being heard; or
• b) is an individual who was involved in an earlier stage of decision making respecting the appeal; or
• c) is a member of the Committee which was responsible for making the decision appealed; or
• d) is otherwise in a conflict of interest with either the Appellant or the Respondent.

5.15. If the Chair of the Committee is unable to sit for any reason, another member of the Committee shall be appointed by the Chair as an acting Chair.

5.16. Where a member of a Committee is challenged by the Appellant or the Respondent on grounds such as conflict of interest, bias or malice, the remaining members of the Committee shall consider the merits of the challenge and determine whether or not the member is disqualified from hearing the appeal. Should a challenge result in a loss of quorum, the Committee shall adjourn and a subsequent hearing shall be scheduled.

5.17. All appeal hearings shall be held in closed sessions. No electronic recording of the proceedings will be allowed.

5.18. Each Appellant and each Respondent shall have the right to appear and have standing before the Committee.

5.19. The Committee may request the Appellant or any other party to appear and/or provide information.

5.20. The parts of the meetings required for deliberation shall be held in camera.

5.21. The Committee shall be prepared to meet as quickly as reasonable in those cases that require prompt action and, in general, shall attempt to handle all appeals with due dispatch.

5.22. If quorum is compromised on the day of the appeal hearing, the Chair will offer both the Appellant and the Respondent the opportunity either to waive quorum and continue with the hearing or have it rescheduled as soon as possible. The appeal hearing will be rescheduled if either party so requests.

5.23. The evidence before the Committee will be weighed on the balance of probabilities.

5.24. The determination of all matters before the Committee will be decided by a simple majority.

5.25. The Chair will vote only in the event of a tie.

5.26. A support staff member from the College of Rehabilitation Sciences will serve as a resource person and recording secretary for the meetings and appeal hearings. The recording secretary shall not have a vote.

5.27. The Appellant may withdraw his/her appeal by informing the Chair of the Undergraduate Student Academic Appeals Committee in writing prior to the start of the scheduled appeal hearing.

5.28. An Appellant who fails to attend, in person, a scheduled appeal hearing may have the appeal considered on the basis of the Appellant’s written submission, the presentation of the Appellant’s representative, if any, and the verbal and written submissions made by the Respondent.

5.29. After the Committee reaches a decision, the Chair will then inform the Appellant, the Respondent and the Dean/Designate of its decision. The Dean/Designate will inform the appropriate Department Head of the decision.

5.30. The decision of the Committee in respect of each appeal shall be binding on the College Council and involved Department.

5.31. If the Undergraduate Student Academic Appeals Committee denies an appeal, a student may appeal to the Senate Committee on Appeals.

5.32. All files on completed cases shall be kept in the Dean’s Office and shall remain confidential.

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6. At the appeal hearing

6.1. The Chair will invite both parties to enter the hearing room and announce the appeal hearing is to be in closed session and that electronic recording of the proceedings is not allowed.

6.2. The Chair shall introduce all parties and outline the appeal hearing process, including the identification of all individuals with standing. The Chair shall ask both parties if they have any questions about the process involved in the appeal hearing and/or the guidelines under which the Committee operates. The Chair shall also confirm that all matters of conflict of interest regarding Committee Membership have been addressed and that both parties have no further concerns regarding these matters.

6.3. During the appeal hearing, the Chair:

• a) may limit oral evidence or oral submissions based on relevance, repetition or privacy;
• b) will not normally permit evidence from witnesses;
• c) determines all questions on admissibility of evidence and the appeal hearing process;
• d) may allow the submission of new information by the Appellant or the Respondent only with the consent of the opposing party;
• e) may seek legal advice. However, the Committee will consider all matters relating to the interpretation of College/Department governing documents.

6.4. The appeal hearing must recess if any Committee member or individual with standing leaves the room temporarily. Either party may request a recess at any point in the appeal hearing. Such a request shall not be unreasonably denied.

6.5. The Committee may, on its own initiative, decide to call, during the appeal hearing, additional resource individuals for further clarification on any issue raised in the appeal.

6.6. The appeal hearing shall proceed as follows:

• a) the Chair shall ask the Appellant or his/her spokesperson, if any, to make an oral statement to the Committee. If the Appellant wishes to make such a statement, it may be used to summarize, elaborate upon, or explain the Appellant's written submission;
• b) the Chair shall invite members of the Committee to ask questions arising from the Appellant’s oral statement and submitted documentation. Cross examination will not be permitted. The Respondent is allowed to ask questions for clarification pertaining to the statement through the Chair;
• c) the Chair shall ask the Respondent or his/her spokesperson, if any, to make an oral statement summarizing or elaborating his/her response;
• d) the Chair shall invite members of the Committee to ask questions arising from the Respondent’s oral statement and submitted documentation. Cross examination will not be permitted. The Appellant is allowed to ask questions for clarification pertaining to the statement through the Chair;
• e) after both parties have presented their statements, Committee members may ask further questions of either party seeking clarification or additional information;
• f) when the Committee is satisfied that it has acquired all of the necessary information, the Chair shall ask each party to make a closing statement;
• g) after both parties have presented their closing statements, the Chair shall temporarily dismiss both parties, and the Committee shall commence its deliberations in camera;
• h) once the Committee enters its deliberations, it shall be polled by the Chair to determine if they have sufficient information to arrive at a decision or if additional information is required;
• i) if the Committee determines that it has received all of the necessary information to come to a decision, the Chair shall release both parties;
• j) if the Committee determines that more information is required, the Chair will recall the parties into the hearing room. Normally, the Committee will receive the additional information through further questions posed to either the Appellant or the Respondent. However, if more detailed information is required, the Committee may reconvene at a later date at which time both parties have the right to be present;
• k) the Committee shall complete its deliberations and voting in camera.

6.7. The Chair of the Committee shall, after a decision has been made, report the results of that decision in writing to the Appellant and the Respondent, and/or their spokespersons, if any. The letter shall include either:

• a) that there is no jurisdiction to hear the appeal, the Appellant has no standing, and/or that there are insufficient grounds to proceed to an appeal hearing; or
• b) a brief summary of the following:
  • (i) the facts of the appeal;
  • (ii) the issues of the appeal; and
  • (iii) brief reasons for the decision of the Committee with specific reference to section 2.3 (grounds) of the Student Academic Appeals Policy.

6.8. All members of the Committee will keep all materials and information used for the appeal in strict confidence and, following the appeal hearing, surrender such materials to the recording secretary who will arrange to have the materials destroyed in a  confidential manner.

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7. Accountability

7.1. The Dean of the College of Rehabilitation Sciences is responsible for advising the Chair of the Undergraduate Student Academic Appeals Committee that a formal review of this Policy is required.

7.2. The Dean or Designate is responsible for the implementation, administration and review of this policy.

7.3. College of Rehabilitation Sciences Council, Academic Staff and Students are responsible for complying with this Policy.

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8. Policy Review

8.1. Governing document reviews shall be conducted every five (5) years. The next scheduled review date for this Policy is June 30, 2028.

• 8.1.1. In the interim, this Policy may be revised or repealed if:
  • 8.1.1.1. Senate or approving body deem necessary or desirable to do so; or
  • 8.1.1.2. The parent policy is revised or repealed.
• 8.1.2.    If this Policy is revised or repealed, all secondary documents will be reviewed as soon as reasonably possible in order to ensure that they:
  • 8.1.2.1. Comply with the revised Policy; or
  • 8.1.2.2. Are in turn repealed.

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9. Cross references

9.1. This policy should be cross-referenced to the following relevant governing documents, legislation and/or forms:

• 9.1.1. College of Rehabilitation Sciences Undergraduate Student Academic Appeals Policy
• 9.1.2. College of Rehabilitation Sciences Undergraduate Student Academic Appeals Committee Terms of Reference
• 9.1.3. College of Rehabilitation Sciences Undergraduate Student Academic Appeal Form
• 9.1.4. University of Manitoba Student Appeals Policy
• 9.1.5. University of Manitoba Senate Committee on Appeals

This Policy is intended to govern and guide decisions regarding Student Attendance in the Dr. Gerald Niznick College of Dentistry, University of Manitoba.

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1.0 Background

The University of Manitoba Dr. Gerald Niznick College of Dentistry has a social mandate to ensure that graduating dentists are caring, skilled healthcare providers who are worthy of the public trust endowed upon them.

To fulfill this mandate, the Dr. Gerald Niznick College of Dentistry has developed comprehensive programs of education and experience.

Collectively, we refer to these programs as Dental School.

Unlike non-professional education programs, where students can pick and choose their education and experiences based on personal preferences, Dental School requires students to attend and participate actively in all components of the program.

While students are required to complete assignments and pass examinations, these are not considered to be equivalent to attending Dental School.

When the University confers the DMD degree, it attests to society not only that the student has shown successful examination performance, but that the student has participated in the entire educational experience defined by the Dr. Gerald Niznick College of Dentistry and has thereby demonstrated an appropriate level of professional learning and responsibility.

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2.0 Statement of Policy

Students at the University of Manitoba, Dr. Gerald Niznick College of Dentistry, are required to attend, and be on time for, all scheduled classes, seminars, examinations, small group sessions, laboratories, pre-clinical labs, and clinics.

Students arriving more than 10-minutes late will be recorded as absent.

Students who do not comply with the Student Attendance Policy will face academic consequences, including, but not limited to:

• Reduced course grades
• Debarment from class, pre-clinical lab, clinic, and/or from final examination(s)
• Debarment from receiving academic credit for the course
• Requirement to repeat a course or year in the program.

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3.0 Statement of Procedures

3.1 Attendance

While student attendance in all scheduled educational experiences is mandatory, monitoring of student attendance in classes and pre-clinical labs is optional and left to the discretion of each Course Coordinator.

Academic consequences for non-attendance may apply in those courses that track student attendance, as detailed in the respective Course Outline.

Tracking of student attendance in scheduled clinics will be performed by the Dean’s Office through use of Axium ‘swipes.’ Information about student attendance in clinic will be communicated regularly with Course Coordinators, who are responsible for following-up with individual students.

Tracking of student attendance in classes and preclinical labs will be performed by the Course Coordinator in each course.

Tracking mechanisms may include I-clicker questions, D2L attendance questions, and/or paper sign-in sheets.

The University of Manitoba welcomes all faiths and beliefs.

As such, the decision regarding absence from class/labs/clinics on religious holidays is left to the individual.

Absences due to religious observance will not contribute to any academic consequence for the student.

Each student is responsible for notifying the College of religious observance dates.

Failure to provide notice will result in the student being classified as absent.

Similarly, special consideration will be given for situations of longer-term student absence due to illness, medical care, or other unavoidable circumstances (see 3.3 below).

3.2 Consequences of Non-attendance

3.2.1 Ideal Attendance:

The target for all students is 100% attendance; the College will consider all students who have achieved this target to have demonstrated an ideal level of professional commitment and responsibility within the dentistry program, and within each course of the program.

3.2.2 Expected Attendance:

Students are allowed a few days absence, up to 5% of the scheduled course sessions, for illness or other non-avoidable reasons, without incurring academic penalty.

The College considers this level of non-attendance to fully meet professional commitments and responsibility within the dentistry program.

For comparison, Manitoba Employment Standards allow 6 unpaid days (3% of available work days) each year for illness, bereavement, and attending to family responsibilities.

3.2.3 Below Expected Attendance:

Student absenteeism beyond 5% of the scheduled course sessions represents what the College will consider to be below expected levels of professional commitment and responsibility with regard to attendance.

Progressive academic consequences, in the form of reduced course grades, will be applied to reflect the degree of non-attendance.

Clinic Attendance:

Students will lose 1% of the course mark for every 1% decrease in clinic attendance; to a maximum of 10% of the course grade (see Table 1 below).

Class/Lab Attendance:

Monitoring of student attendance in class/lab is optional, and left to the discretion of the Course Coordinator.

For courses opting to monitor student attendance, the course-specific academic consequences for non-attendance will be detailed in the Course Outline.

The maximum academic penalty for non-attendance is 10%.

3.2.4 Unacceptable Attendance:

The minimum acceptable level of attendance is 85% for each course in the dentistry program.

Course Coordinators or the Associate Dean (Academic) can initiate procedures to debar a student from attending class, pre-clinical labs, clinics, or from final examinations, when the absences for that student exceed 15% of the available academic time in a course.

When notified of a course attendance problem, the Associate Dean (Academic) will call, and give notice to the student, of a Disciplinary Hearing to investigate the issue under the U of M Student Discipline Bylaw.

If it is determined that the student is in breach of this Student Attendance Policy, then debarment from class, pre-clinical lab, clinic, and/or from final examination(s) is possible.

In addition to the above ‘course-level’ academic consequences, students found to be in breach of this Student Attendance Policy, with absenteeism exceeding 15% of the available academic time in a course, may be debarred from receiving academic credit for the course and be required to repeat the course or year in the program.

Table 1: Academic consequences for clinical non-attendance

Attendance (of scheduled clinics)	Academic Consequences
95-100%	No penalty
94%	1% penalty
93%	2% penalty
92%	3% penalty
91%	4% penalty
90%	5% penalty
89%	6% penalty
88%	7% penalty
87%	8% penalty
86%	9% penalty
85%	10% penalty
<85%	Debarment

3.3 Special consideration for extended illness/medical care

Students are allowed a reasonable number of absences due to illness or for compassionate reasons before incurring academic consequences (see 3.2 above).

In cases of longer-term (greater than 3 days) illness, or other extended or recurring absence, students can submit a formal written request to the Associate Dean (Academic) detailing the reasons why special consideration should be given for the student’s attendance.

The Associate Dean (Academic) will decide whether or not normal academic consequences should apply.

These requests will normally require a signed physician's certificate or other external documentation of the reason for non-attendance.

Academic consequences will normally be waived for extended absence for unavoidable, documented illness, healthcare, and compassionate reasons.

3.4 Absence from Clinics with Booked Patients

The Dentistry Program includes some clinics where students book their own patients, and some clinics where College staff book patients for the students.

The latter includes the Pediatric Dentistry, Orthodontic, 4th year General Practice, Urgent Care, Oral Surgery, Oral Sleep Medicine, TMD, and Community Externship rotation clinics.

The convenience of having patients booked by College staff brings an additional professional responsibility regarding absence on these clinic days.

Absence without notification on these dates would result in harm to the patient (abandonment, lost time from work), inconvenience to staff and fellow students, and harm to the reputation of the College and University.

On days when a student will be absent from a clinic with booked patients, including days of unexpected illness in the morning, the student is required to report the absence to the Faculty prior to the scheduled patient appointment time.

For student convenience, all contact regarding absence should be directed to the Student Services Office at 204-480-1355 or by email to absent@umanitoba.ca.

When notified that a student is absent without notice from a clinic with booked patients, the Associate Dean (Academic) will call, and give notice to the student, of a Disciplinary Hearing to investigate the issue under the Student Discipline Bylaw, or the Professional Unsuitability Bylaw for repeated offenses.

If it is determined that the student is in breach of this Student Attendance Policy, then more serious academic consequences, including suspension or expulsion is possible.

For details of possible consequences see:

• http://umanitoba.ca/admin/governance/media/Student_Discipline_Bylaw_-_Table_2.pdf
• http://umanitoba.ca/faculties/dentistry/media/Dentistry_Professional_Unsuitability_Bylaw.pdf .

3.5 Examinations

Students are required to attend all scheduled examinations.

A student who is prevented from attending any regular examination, by reason of illness or other cause beyond his or her control, must at once notify the College prior to the start of the examination, and give satisfactory evidence of the cause of absence.

Students failing to provide prior notice and satisfactory evidence will receive a mark of zero (“0”) on the missed examination.

If the absence was necessary by reason of illness, then the student MUST provide a physician’s certificate to avoid a mark of zero (“0”).

The College reserves the right to require the physician’s note to be from a University of Manitoba Health Service Clinic, and to confirm the validity of any submitted physician’s certificate.

3.5 Communication of the Policy

The Policy will be reviewed with students each year during the orientation period.

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4.0 University and College Expectations

The above stated Policy and Procedures are designed to govern and guide decisions regarding student attendance in the DMD program at the Dr. Gerald Niznick College of Dentistry , and are complementary and supportive to the following University of Manitoba Policy on Attendance and Withdrawal excerpted from the Undergraduate Calendar.

Attendance and Withdrawal

1. Attendance at Class and Debarment

Regular attendance is expected of all students in all courses.

An instructor may initiate procedures to debar a student from attending classes and from final examinations and/or from receiving credit where unexcused absences exceed those permitted by the faculty or school regulations.

A student may be debarred from class, laboratories, and examinations by action of the dean/director for persistent non-attendance, failure to produce assignments to the satisfaction of the instructor, and/or unsafe clinical practice or practicum.

Students so debarred will have failed that course.

Essential skills and abilities for admission, promotion and graduation in the Doctor of Dental Medicine (DMD) program

All matters concerning ‘professionalism’ are governed by the Dr. Gerald Niznick College of Dentistry Professional Unsuitability Bylaw, and those concerning other listed skills and abilities are governed by the Dr. Gerald Niznick College of Dentistry Essential Student Abilities Bylaw.

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Preamble

As an accredited Canadian dental program, the Dr. Gerald Niznick College of Dentistry at the University of Manitoba is responsible for providing a program of study that ensures graduates have the necessary qualifications (academic knowledge, clinical skills, and professional behaviors and attitudes) to enter the regulated profession of Dentistry in Canada. Becoming and being a dentist requires a wide range of highly specialized skills and abilities. Some of these are taught in dental school, while others must be brought by the individual as an innate set of essential skills and abilities. The criteria for becoming registered/ licensed as a dentist in Canada requires a level of motor skills and other attributes that are not necessary in other professional occupations. Similarly, the ability to provide reasonable accommodation for special learning needs in dentistry may not be the same as it is for other academic programs. For example, patient safety concerns with restorative and surgical procedures preclude the ability to accommodate additional time to complete, and assess, student clinical procedures. This document describes the skills and abilities required for success in completing the dental program. Students interested in becoming a dentist must review this document.

It is important to note that an offer of admission to the Dr. Gerald Niznick College of Dentistry is not evidence that the dental program has verified that an applicant has the prerequisite skills and abilities for success in the program. However, these skills and abilities are essential if students are to be successful in achieving the competency standards of the profession. Further, in order to be registered/licensed as a dentist in Canada, individuals must successfully complete the National Dental Examining Board of Canada (NDEB) examination. As such, the skills and abilities required to successfully complete the NDEB examination are included as skills required in the program.

For progression in, and graduation from the dental program, all students must conduct themselves in a professional manner, and must have the Essential Skills and Abilities (Technical Standards) discussed under the following five broad areas:

• observation/perception
• communication
• motor/tactile function
• cognition
• emotional functioning

All applicants to the undergraduate program of the Dr. Gerald Niznick College of Dentistry are expected to review this document to assess their ability to meet these standards; all applicants offered admission will be required to acknowledge such review and assessment. Any candidate for the DMD degree who cannot demonstrate the required skills and abilities throughout their course of study may be requested to withdraw from the program.

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Essential skills and abilities

An applicant to the DMD program and a candidate for the DMD degree must reasonably expect that while enrolled in the undergraduate dental program they will be able to demonstrate an appropriate degree of professionalism, and will be able to demonstrate the following skills and abilities:

Professionalism
Students are obligated to act with integrity and diligence in carrying out their professional responsibilities, and their behavior and conduct in relation to others must be characterized by consideration, respect and good faith.

Technical Standards

(1) Observation/perception
A student must be able to participate in learning situations and acquire information through observation and perception by the use of senses and mental abilities. In particular, a student must participate progressively in patient encounters and acquire information through acute visual and tactile sensation.

(2) Communication
A student must be able to speak, hear and write proficiently in the English language, and to observe individuals and groups of individuals in order to effectively and efficiently elicit and clarify information. The student must be able to progressively create rapport and develop therapeutic relationships with patients, and establish effective communication with all members of the dental school community and other healthcare teams. A student must be able to coherently summarize and effectively communicate a patient’s condition and management plan verbally, and in written and electronic forms.

(3) Motor/tactile function
A student must possess sufficient motor function to develop the skills required to safely perform fine diagnostic, preventive, restorative (e.g. fillings) and surgical procedures on a patient. These procedures must be done independently and competently in a timely fashion to minimize the risk to patient safety. A student must possess fine motor function and sensory function in order to be able to use common dental instrumentation including for example, an explorer, syringe, dental handpiece (drill) and surgical scalpel.

(4) Cognition
A student must demonstrate higher-level cognitive abilities necessary to measure, to calculate, and to reason in order to conceptualize, analyze, integrate and synthesize information. The student must be able to comprehend dimensional and visual-spatial relationships. All of these problem-solving activities must be achieved progressively in a timely fashion and must contribute to sound judgment based upon clinical and ethical reasoning.

(5) Emotional functioning
A student must be able to tolerate the physical, emotional, and mental demands of the program and function effectively under stress. It is necessary to be able to adapt to changing environments, and to function in the face of uncertainties that are inherent in the care of patients. Decisions and procedures must be completed in a timely manner in order to maximize patient outcomes and minimize risks to patient safety.

Policy:	Student academic appeals
Effective date:	January 25, 2016
Revised date:	May 1, 2023
Review date:
Approving body:	Dental College Council
Authority:	Dental College Council
Responsible executive officer:	Dean – Dr. Gerald Niznick College of Dentistry
Delegate:	Associate dean – Dr. Gerald Niznick  College of Dentistry
Contact:	Chair, Student Academic Appeals Committee
Application:	College/school council; students; academic staff

Part I: Reason for Policy

1.1    The Student Academic Appeals Policy (the “Policy) and related Procedures (the “Procedures”) provide guidance to Dr. Gerald Niznick College of Dentistry/School of Dental Hygiene members charged with determining appeals of an academic nature upon application by the Appellant. These include: appeals of term work; final grades; and decisions of Dental College Council including decisions related to the Professional Unsuitability Committee and the Academic Award Selection Committee. This policy does not pertain to those decisions related to admission, tuition, disciplinary matters, or human rights issues.

1.2    The Policy, and related Procedures, also provides guidance to Appellants and their right of appeal to the Student Academic Appeals Committee (the “Committee”).

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Part II: Policy content

2.1    Definitions:

The following terms have the following defined meanings for the purpose of this Policy and its Procedures:

1. Appellant – the student appealing a decision affecting the student’s own academic standing within the College of Dentistry/School of Dental Hygiene
2. Chair – the Chair of the Student Academic Appeals Committee
3. Committee – the Student Academic Appeals Committee
4. Members – members of the Student Academic Appeals Committee convened for the purpose of:
   1. Determining its jurisdiction
   2. Determining the Appellant’s standing and whether there are grounds of appeal; or
   3. Hearing appeals

5. Respondent – a representative or representatives of the College/School designated by the Dean/Designate or Director to represent the College/School in relation to an appeal.

2.2    There shall be a Student Academic Appeals Committee:

1. that shall make decisions on appealable matters that shall be final and binding within the College.

2. That shall review the Student Academic Appeals Policy and related Procedures periodically and if necessary, recommend changes to Dental College Council.
3. That shall hear academic appeals from decisions of Department Heads/Director regarding marks assigned to term work, final grades and/or decisions of Dental College Council upon request by students.
4. That shall inform the Dean/Designate of the results of all appeals submitted to it.
5. That shall prepare and submit an annual report for presentation to Dental College Council.

2.3    The grounds for an appeal to be heard by the Committee shall include:

1. Failure of the College/School or Dean/Director to follow procedures

2. Failure of the College/School or Dean/Director to follow the rules of natural justice
3. Failure of the College/School or Dean/Director to reasonably consider all factors relevant to the decision being appealed
4. That a College/School/Faculty/Senate governing document has become inapplicable through lapse of time or was unfairly applied
5. That there is an apparent conflict between a Senate governing document and a College/School/Faculty governing document
6. Failure of Senate, the College/School/Faculty, or Dean/Director to comply with applicable legislation

2.4    Composition of Committee:

1. One (1) faculty member appointed by the Dental College Council Executive as Chair

2. Two (2) faculty members from the College of Dentistry (One basic scientist and one clinician) and one (1) faculty member from the School of Dental Hygiene elected by Dental College Council 
3. One (1) dental student and one (1) dental hygiene student appointed annually by their respective Students’ Association and ratified by Dental College Council. A student member shall serve at appeal hearings only if the appellant is from their constituency.
   document and a College/School/Faculty governing document
4. Where possible the composition of the Committee shall maintain an equitable gender balance.
5. A list of alternate membership will be established to act in reserve, pending availability and/or suitability (i.e., conflict of interest situations) of original committee membership. Members of this alternate list will be called upon to serve as necessary and in a manner which maintains the composition of the committee as detailed above.

2.5    A quorum for a meeting of the Committee shall be three (3) members including the Chair; except for appeal hearings where the quorum is four (4) members, including the Chair.

2.6    The Chair of the Committee shall be appointed by Dental College Council Executive.

2.7    Committee Members shall serve three (3) years unless otherwise specified.

2.8    Vacancies on the Committee shall be filled by the original bodies that made the appointment or conducted the election.

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Part III: Accountability

3.1    The Dean of the Dr. Gerald Niznick College of Dentistry is responsible for advising the Chair of the Student Academic Appeals Committee that a formal review of this Policy is required.

3.2    The Dean or Designate is responsible for the implementation, administration, and review of this policy.

3.3    Dental College Council, Academic Staff and Students are responsible for complying with this Policy.

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Part IV: Authority to approve procedures

4.1    The Approving Body may approve Procedures, if applicable, which are secondary to and comply with this Policy.

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Part V: Review

5.1    Governing Document reviews shall be conducted every five (5) years. The next scheduled review date for this Policy is May 2028.

5.2    In the interim, this Policy may be revised or repealed if:

1. Senate or Approving Body deem necessary or desirable to do so; or

2. The relevant Governing Documents are revised or rescinded.

5.3    If this Policy is revised or repealed, all Secondary Documents will be reviewed as soon as reasonably possible to ensure that they:

1. comply with the revised Policy; or

2. are in turn repealed.

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Part VI: Effect on previous statements

6.1    This Policy supersedes all of the following:

1. Student Appeals Committee (approved October 5, 1981); and

2. All previous Governing Documents on the subject matter contained herein

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Part VII: Cross references

7.1    This policy should be cross referenced to the following relevant Governing Documents, legislation and/or forms:

1. Student Academic Appeals Procedures

Procedure:	Student academic appeals
Parent policy:	Student academic appeals policy
Effective date:	January 25, 2016
Revised date:	May 1, 2023
Review date:
Approving body:	Dental College Council
Authority:	Dental College Council
Responsible executive officer:	Dean – Dr. Gerald Niznick College of Dentistry
Delegate:	Associate dean – Dr. Gerald Niznick College of Dentistry
Contact:	Chair, Student Academic Appeals Committee
Application:	College/school council; students; academic staff

Part I: Reason for procedure

1.1 To set out Procedures secondary to the Policy entitled “Student Academic Appeals” in order to establish a process for appeals to be heard, and to provide guidance to the members of the Student Academic Appeals Committee, the Appellant and the College/School representatives in relation to appeal hearings.

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Part II: Procedural content general

2.1 Dental College Council, in approving these Procedures, wishes to impress upon the parties appearing before the Committee that the appeal hearing is intended to be a review of the facts which bear on the issues before the Committee. Questions by the Committee members to the Appellant and to the Respondent during the appeal hearing should be expected. Nothing in these Procedures should be taken, however, as relieving the Appellant of the responsibility of making a submission and presenting evidence in support of their appeal.

2.2 Prior to submitting an appeal to the Committee, the Appellant must have exhausted all procedures and appeal processes available to them at the Department/School/College level and/or the Registrar’s Office (grade appeal).

1. Processes for the review of Term Work (to include Term Exams)
   1. Students desiring to discuss matters relating to marks assigned to term work should discuss the matter with the Course Coordinator/ Instructor.
   2. Requests by students to review term work are to occur within ten working days of the notification of marks for the term work.
   3. Term work is to be retained by the department/course coordinator where possible and should be kept until six months after the expiration of the appeal period.
   4. If term work is not able to be retained by the course coordinator/instructor for future reassessment, marks in the D/F range shall, in so far as possible, be reassessed by an independent consulting instructor in a blinded fashion prior to returning the term work to the students. The reassessments should be signed and dated by the consulting instructor and kept for a period of six months after the expiration of the appeal period.
   5. Term work marks subject to review/reassessment may not be lowered.
2. Processes for the Appeal of Term Work including Term Exams
   1. If the review process for term work has been completed and the student wishes to file a formal appeal at the departmental level, they may do so within 10 working days of receiving the mark.
   2. The procedure and fees associated with each term work appeal will follow the University of Manitoba Term Work Appeal Form available online.
3. Processes for the Appeal of Final Grades
   1. In the first instance, if it is believed that an error was made, the matter should be discussed with the Course Coordinator/Instructor. If appropriate, a Change of Grade form may be submitted through the Department.
   2. A student may enter an appeal through the Registrar’s Office for assessment of one or more Final Grades following procedures and timelines as outlined in the University of Manitoba Final Examination and Final Grades Procedures Document. Application must be made to the Registrar’s Office in accordance with the regulations and deadlines to file an appeal as posted on the Registrar’s Office website. On payment of the prescribed fee, such appeals will be forwarded to the Head of the Department in which the course is offered.
   3. Normally, the re-evaluation of a grade shall be undertaken by the course coordinator and instructor(s) responsible for the particular course in consultation with at least one other instructor – who shall, and as far as is possible, independently assess the final examination script and/or other relevant materials, in a blinded fashion.
   4. With respect to the reassessment of the final grades:
      • In the event that the appealed grade has been awarded on the basis of a final examination only, the entire final examination script will be re- read.
      • Except as noted below, where the grade has been awarded on the basis of a final examination in combination with term work, the final examination script willbe re-read, and the term mark calculation reviewed.
      • In the case of grades awarded solely on the basis of term work except as noted below, the calculation only will be reviewed.
      • In instances where term work has been retained by the course coordinator/instructor that term work shall also be re-read.
   5. An appealed grade may not be lowered.
   6. Final examination scripts are to be held by the teaching unit responsible for the course until six months after the expiration of the appeal period. In individual cases where appeals have been initiated, the holding period will be extended accordingly.
   7. Teaching units shall be responsible for destroying examination scripts held by them in accordance with these procedures, ensuring in the process of confidentiality of the documents.
   8. Students whose grades are reassessed as the result of an appeal initiated through the Registrar’s Office may subsequently appeal to the Student Academic Appeals Committee.

Filing an Appeal with the Student Academic Appeals Committee

2.3 A Student may file an appeal, along with all relevant documentation, with the Dean of the College of Dentistry within 10 working days following notification of:

1. a College Council decision of an academic nature that directly affects them; or
2. a College Council decision of an academic nature that directly affects them; or
3. a decision by a Department Head/Director regarding an appeal of one or more marks assigned to term work.

2.4 If an Appellant files an appeal beyond the ten (10) working days period, the Appellant must provide written reasons for the delay. The Chair shall have the discretion to extend the deadline for filing an appeal if it is determined that there are special circumstances which justify or excuse the delay. The Chair’s decision is final and not appealable.

2.5 The Appellant must submit all documentation that will be relied on for the appeal and must include the following:

1. A completed and signed Student Appeals Form (PDF) which is also available at the Dean’s/Director’s Office..
2. A letter to the Chair clearly explaining the nature and grounds for the appeal, with specific reference to sections 2.3 of the Student Academic Appeals Policy and Procedure documents
3. A copy of the letter of decision from the last appeal level
4. A copy of all documentation submitted to the last appeal level
5. The remedy sought of the Committee; note that this should not differ from that requested at the last appeal level unless extraordinary circumstances are presented
6. The names and contact information of any witnesses who will accompany and assist the Appellant at the hearing. Relevance of the witnesses must be demonstrated in the submitted documentation. Their attendance at the hearing is at the discretion of the Chair
7. The name and contact information of any spokesperson
8. The name and contact information of any lawyer who may be present as an observer
9. Additional information/documents submitted after the filing of the appeal will be considered new information. It will be assessed for admissibility by the Chair and will only be allowed with the consent of the opposing party.

All submitted documents are considered confidential and will be subject to the provisions of The Freedom of Information and the Protection of Privacy Act and The Personal Health Information Act.

2.6 The Appellant shall have the right to be accompanied by a spokesperson:

1. This spokesperson may be an advocate from the Student Advocacy Office or a representative of the University of Manitoba Students’ Union, or other full-time member of the University community not receiving payment for appearing or a member of the Appellant’s immediate family.
2. In addition, a lawyer may be present, but as an observer only, who does not participate.
3. It is the Appellant’s sole responsibility to ensure:
   1. That their spokesperson is familiar with the College of Dentistry Student Academic Appeals Policy and Procedures
   2. The adequacy of their representation

2.7 The Dean shall forward copies of the written appeal to the Chair of the Student Academic Appeals Committee, the Dean’s designated Respondent(s) if applicable and the Head of the appropriate Department/or the Director of the School of Dental Hygiene.

2.8 The Chair of the Student Academic Appeals Committee shall inform the members of the Committee of the nature of the appeal, and call a meeting to determine jurisdiction; whether the Appellant has standing; and whether there are sufficient grounds for the appeal to be heard. The Chair, at their discretion, may invite the parties to make submissions on the question of jurisdiction or standing. The Chair shall direct the Committee that, in its consideration of holding a hearing, the benefit of the doubt will always be given to the Appellant.

2.9 If the Committee determines that there is no jurisdiction to hear the appeal, and/or the Appellant has no standing, and/or there are insufficient grounds to consider an appeal, the appeal will be deemed dismissed and the Chair will inform the Appellant and the Dean by letter.

2.10 If the Committee determines that there is jurisdiction to hear the appeal, the Appellant has standing, and there are sufficient grounds, the Chair shall:

1. inform the Appellant, the Dean, the designated Respondent(s) and the Department Head/Director in writing that a hearing will be held and the reason for the hearing.
2. inform the Appellant, the Dean, the designated Respondent(s) and the Department Head/Director of Committee Membership, along with a deadline to submit concerns regarding perceived conflicts.
3. Request that the Dean or designated Respondent(s) provide a written response to the appeal. At least ten (10) working days must be allowed in which to provide this written response back to the chair.
4. Establish a date for the hearing based upon availability of the Appellant, Respondent(s) and any resource person(s) as identified in their documentation.

2.11 If the Respondent(s) request an extension beyond the ten (10) working days, they must provide written reasons for the delay. The Chair shall have the discretion to extend the deadline for filing a response if it is determined that there are special circumstances which justify or excuse the delay. The Chair’s decision is final and not appealable.

2.12 The Respondent(s) must submit all documents that will be relied on for the appeal and must include the following:

1. A letter to the Chair clearly outlining the response to the appeal
2. The names and contact information of any witnesses who will accompany and assist the Respondent at the hearing. Relevance of the witnesses must be demonstrated in the submitted documentation. Their attendance at the hearing is at the discretion of the Chair.
3. The name and contact information of any lawyer who may be present as an observer.
4. Additional information/documents submitted after the filing of the response will be considered new information. It will be assessed for admissibility by the Chair and will only be allowed with the consent of the opposing party.

All submitted documents are considered confidential and will be subject to the provisions of The Freedom of Information and the Protection of Privacy Act and The Personal Health Information Act.

2.13 The Chair shall provide the Appellant with copies of the written response by the Respondent(s) prior to the date of the hearing.

2.14 All members of the Student Academic Appeals Committee will be provided with the Student Academic Appeals Policy and Procedures documents.

2.15 In the cases of absence of members or possible conflicts of interest relative to any members of the Student Academic Appeals Committee, the Chair shall appoint an alternate for the duration of the appeal (see section 2.3 of the Student Academic Appeals Policy).

2.16 In the event that the Chair appoints an alternate to the committee it should be assured that the resultant committee composition does not give rise to perceived gender bias and follows, where possible, the membership composition (section 2.3 Student Academic Appeals Policy).

2.17 All appeal hearings shall be held in closed session(s). No taping or recording of the proceedings will be allowed.

2.18 Each Appellant and each Respondent shall have the right to appear and have standing before the Committee.

2.19 The Committee may request the Appellant or any other party to appear and/or provide information.

2.20 The parts of the meetings required for deliberation shall be held in camera.

2.21 The Committee shall be prepared to meet as quickly as reasonable in those cases that require prompt action and, in general, shall attempt to handle all appeals with due dispatch.

2.22 If quorum is compromised on the day of the appeal hearing, the Chair will offer both the Appellant and the Respondent the opportunity either to waive quorum and continue with the hearing or have it rescheduled as soon as possible. The appeal hearing will be rescheduled if either party so requests.

2.23 The evidence before the Committee will be weighed on the balance of probabilities.

2.24 The determination of all matters before the Committee will be decided by a simple majority.

2.25 The Chair will vote only in the event of a tie.

2.26 A staff member from the Dean’s Office, College of Dentistry will serve as a resource person and recording secretary for the meetings and appeal hearings. The recording secretary shall not have a vote.

2.27 The Appellant may withdraw their appeal by informing the Chair of the Student Academic Appeals Committee in writing prior to the start of the scheduled appeal hearing.

2.28 An Appellant who fails to attend a scheduled appeal hearing may have the appeal considered on the basis of the Appellant’s written submission, the presentation of the Appellant’s spokesperson, if any, and the verbal and written submissions made by the Respondent.

2.29 After the Committee reaches a decision, the Chair will then inform the Appellant, the Respondent(s) and the Dean of its decision. The Dean will inform the appropriate Department Head/Director of the decision.

2.30 The decision of the Committee in respect of each appeal shall be binding on the College Council and involved Department/School.

2.31 If the Student Academic Appeals Committee denies an appeal, a student may appeal to the Senate Appeals Committee.

2.32 All files on completed cases shall be kept in the Dean’s Office and shall remain confidential.

At the Appeal Hearing:

2.33 The Chair will invite both parties to enter the hearing room and announce the appeal hearing is to be in closed session and that taping/recording of the proceedings is not allowed.

2.34 The Chair shall introduce all parties and outline the appeal hearing process, including the identification of all individuals with standing. The Chair shall ask both parties if they have any questions about the process involved in the appeal hearing and/or the guidelines under which the Committee operates. The Chair shall also confirm that all matters of conflict of interest regarding Committee Membership have been addressed and that both parties have no further concerns regarding these matters.

2.35 During the appeal hearing, the Chair:

1. may limit oral evidence or oral submissions based on relevance, repetition or privacy;
2. determines all questions on admissibility of evidence and the appeal hearing process;
3. may allow the submission of new information by the Appellant or the Respondent(s) only with the consent of the opposing party;
4. may seek legal advice. However, the Committee will consider all matters relating to the interpretation of Senate, College/School/Department governing documents.

2.36 The appeal hearing must recess if any Committee member or individual with standing leaves the room temporarily. Either party may request a recess at any point in the appeal hearing. Such a request shall not be unreasonably denied.

2.37 The Committee may, on its own initiative, decide to call, during the appeal hearing, additional resource individuals for further clarification on any issue raised in the appeal.

2.38 The appeal hearing shall proceed as follows:

1. the Chair shall ask the Appellant, or their spokesperson, if any, to make an oral statement to the Committee. If the Appellant wishes to make such a statement it may be used to summarize, elaborate upon, or explain the Appellant's written submission;
2. the Chair shall invite members of the Committee to ask questions arising from the Appellant’s oral statement and submitted documentation. Cross examination will not be permitted;
   The Respondent(s) are allowed to ask questions for clarification pertaining to the statement through the Chair;
3. the Chair shall ask the Respondent(s), or their spokesperson, if any, to make an oral statement summarizing or elaborating their response;
4. the Chair shall invite members of the Committee to ask questions arising from the Respondent(s)’s oral statement and submitted documentation. Cross examination will not be permitted. The Appellant is allowed to ask questions for clarification pertaining to the statement through the Chair;
5. after both parties have presented their statements, Committee members may ask further questions of either party seeking clarification or additional information;
6. when the Committee is satisfied that it has acquired all of the necessary information, the Chair shall ask each party to make a closing statement;
7. after both parties have presented their closing statements, the Chair shall temporarily dismiss both parties, and the Committee shall commence its deliberations, in camera;
8. once the Committee enters its deliberations, it shall be polled by the Chair to determine if they have sufficient information to arrive at a decision or if additional information is required;
9. if the Committee determines that it has received all of the necessary information to come to a decision, the Chair shall release both parties;
10. if the Committee determines that more information is required, the Chair will recall the parties into the hearing room. Normally, the Committee will receive the additional information through further questions posed to either the Appellant or the Respondent(s). However, if more detailed information is required, the Committee may reconvene at a later date at which time both parties have the right to be present;
11. the Committee shall complete its deliberations and voting in camera.

2.39 The Chair of the Committee shall, after a decision has been made, report the results of that decision in writing to the Appellant and the Respondent(s), and/or their spokespersons, if any. The letter shall include either:

1. that there is no jurisdiction to hear the appeal, the Appellant has no standing, and/or that there are insufficient grounds to proceed to an appeal hearing; or
2. a brief summary of the following:
   1. the facts of the appeal;
   2. the issues of the appeal; and
   3. brief reasons for the decision of the Committee with specific reference to section 2.3 of the Student Academic Appeals Policy.

2.40 All members of the Committee will keep all materials and information used for the appeal in strict confidence and, following the appeal hearing, surrender such materials to the recording secretary who will arrange to have the materials destroyed in a confidential manner.

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Part III: Accountability

3.1 The Dean of the College of Dentistry is responsible for advising the Chair of the Student Academic Appeals Committee that a formal review of this Policy is required.

3.2 The Dean or Designate is responsible for the implementation, administration and review of this policy.

3.3 Dental College Council, Academic Staff and Students are responsible for complying with this Procedure.

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Part IV: Review

4.1 Governing Document reviews shall be conducted every five (5) years. The next scheduled review date for this Procedure is May 2028.

4.2 In the interim, this Procedure may be revised or repealed if:

1. Senate or Approving Body deem necessary or desirable to do so; or
2. The Parent Policy is revised or repealed.

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Part V: Effect on previous statements

5.1 This Procedure supersedes all of the following:

1. Student Appeals Committee (approved October 5, 1981; Revised March 28, 1994; January 25, 2016); and

2. all previous Administration Governing Documents on the subject matter contained herein.

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Part VI: Cross references

6.1 This Procedure should be cross referenced to the following relevant Governing Documents, legislation and/or forms:

1. Student Academic Appeals Policy

2. Student Appeals Form (PDF)

Policy name	Adult criminal records , child abuse registry, adult abuse registry and Basic Life Support (BLS) for Health Care Providers (HCP) information specific to the time of admission and annual re-registration
Policy number
Application and scope	Applicants to the MD Degree Program, undergraduate medical education students and to the MPAS Program
Approved date	April, 2017
Review date	January 2021
Revised date	January 2017
Approved by	College Executive Council

1. POLICY STATEMENTS

The Max Rady College of Medicine requires that all applicants accepted to the College’s medical education programs:

1.1 Must submit and be cleared on a formal Criminal Records Check (including vulnerable sector screening) by the time of their initial registration and prior to each subsequent annual re-registration.

• The original documents must be verified by UGME Enrolment

• Services after which they will be returned to the learner.

• Criminal Records Checks can be obtained online, from your local law enforcement agency, or from the Winnipeg Police Service.

1.2 Must submit and be cleared on a formal Child Abuse Registry Check by the time of their initial registration and prior to each subsequent annual re-registration.

• Child Abuse Registry Checks can be completed at the Educational Programs Office, 260 Brodie Centre during regular business hours. Students must bring two pieces of government-issued identification to complete the application.
• UGME Enrolment Services will receive the original documents directly from the respective government offices.

1.3 Must submit and be cleared on a formal Adult Abuse Registry Check by the time of their initial registration and prior to each subsequent annual re-registration.

• Adult Abuse Registry Checks can be completed at the Educational Programs Office, 260 Brodie Centre during regular business hours. Students must bring two pieces of government-issued identification to complete the application.
• UGME Enrolment Services will receive the original documents directly from the respective government offices.

1.4 Must complete a recent Basic Life Support (BLS) for Health Care Providers (HCP) course and submit proof of course completion by the time of their initial registration and prior to each subsequent annual re-registration.

• Session information for University of Manitoba course offerings can be found online. Sessions conducted outside of the University of Manitoba will be accepted as long as it is a Basic Life Support (BLS) for Health Care Providers (HCP) Course acceptable to the Heart & Stroke Foundation.

1.5 Must immediately advise the Associate Dean, UGME and Director MPAS if charged with or convicted of any offence under the Criminal Code, Controlled Drugs and Substances Act or Food and Drugs Act at any time during the learner’s registration in the Max Rady College of Medicine’s educational programs. If the learner is charged with or convicted of such an offence while not actively registered, the Associate Dean, UGME or Director of MPAS must be advised at the time of annual re-registration. W here a charge or conviction is disclosed, the Associate Dean may refer the matter to Faculty’s Professionalism Subcommittee on Admissions and Progression, which will determine the appropriate course of action. Failure to disclose a criminal charge or conviction in a timely manner, or at all, may lead to citation for breach of professionalism and ramifications may include expulsion from the educational program.

Please be advised of the following pertinent information.

1.6 Adult criminal convictions or pending charges will not necessarily preclude admission or re-registration. If a conviction is disclosed, the decision on how that will affect the candidate will be made by the Faculty’s Professionalism Subcommittee on Admissions and Progression. This Committee will consist of the following: the Associate Dean, Professionalism and Diversity as Chairperson; the Associate Dean, Postgraduate Medical Education; the Executive Director of the Joint Operating Division or designate; the Registrar of the College of Physicians and Surgeons of Manitoba or designate; and a student representative. The Committee may determine that a candidate is eligible for admission, eligible for admission under specified conditions, or ineligible for admission; the Committee may similarly determine the parameters for continued registration or dismissal. However, applicants to a medical education program, or those currently enrolled who have adult criminal convictions which indicate they may pose a threat to the safety and well- being of children and others will be denied admission or continued registration.

1.7 Candidates are not required to disclose records under The Youth Criminal Justice Act.

1.8 Candidates for admission who appear on the Child Abuse Registry or Adult Abuse Registry as an offender will be denied admission, and registered learners who subsequently are added will be withdrawn from the medical education program

1.9 The formal checks are the property of the learner and will be returned to the learner.

2.0 The College of Physicians and Surgeons of Manitoba has requirements for registration that include a criminal record check suitable to the College; such requirements are independent from the Max Rady College of Medicine. College requirements can be accessed on their website.

The Max Rady College of Medicine, University of Manitoba cannot be held responsible for future changes in legislation which may affect requirements for registration and licensure to practice medicine in Manitoba.

2.1 Notwithstanding requirements identified in A. 3, any changes in a learner’s criminal record status, Child Abuse Registry status or Adult Abuse Registry status as an offender while in the College’s medical education programs must be reported to the Associate Dean, UGME, who will then consult with the Faculty committee described above.

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2. POLICY CONTACT

Please contact Administrator, Enrolment with questions respecting this policy.

Policy name	Criteria for doctor of medicine graduand list
Policy number
Application and scope	Undergraduate Medical Education (UGME) students
Approved date	August 16, 2022
Review date	Five (5) years after revised date (January 2027)
Revised date	January 2022
Approved by	College Executive Council

1. PURPOSE

To establish the process for preparing and approving the respective Max Rady College of Medicine MD Graduand lists for Spring and Fall Convocation.

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2. DEFINITIONS

2.1 Prospective Spring Graduand List - The list of students in the final year of the MD degree program who are expected to meet the graduation requirements by the official dates for Spring Convocation as reflected in the current University Academic Calendar.

2.2 Prospective Fall Graduand List -The list of students in the final year of the MD degree program who are expected to meet the graduation requirements by the official dates for Fall Convocation as reflected in the current University Academic Calendar.

2.3 National Board of Medical Examiners (NBME) Exam – A multiple-choice examination developed by the NBME that is administered at the end of the Surgery, Internal Medicine, Obstetrics/Gynecology and Reproductive Sciences, Pediatrics, Family Medicine, and Psychiatry clinical rotations at the Clerkship level of the UGME program.

The NBME will recommend a pass mark as an equated percent correct score, and the UGME Program will determine the pass mark every September, based on this recommendation.

2.4 Deferred Examination – An approved delay in writing a summative examination.

2.5 Supplemental Examination - An opportunity to rewrite an examination that was failed.

2.6 Remediation – The provision to students on Probationary Status by the Undergraduate Medical Education Faculty of reasonable academic supports, educational resources and protected time for studying and review, and additional clinical exposures as may be deemed appropriate following a Remediation Assessment.

2.7 ACLS (Advanced Cardiac Life Support) - A course covering clinical interventions for the urgent treatment of cardiac arrest, stroke, and other life-threatening medical emergencies and knowledge and skills to deploy these interventions.

2.8 Final Spring Graduand List - The list of students who have met all requirements for Spring Convocation.

2.9 Final Fall Graduand List - The list of students who have met all requirements for the Fall Convocation.

2.10 Elective - An opportunity for self-education in the student’s interest area.

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3. POLICY STATEMENTS

SPRING CONVOCATION

3.1 A Year IV student’s name is sent forward for Convocation if the student meets the following requirements no later than the College Executive Council session scheduled in early to mid- April of each academic year:

• Completion of all Remediation;
• Completion of all NBME Examinations – Deferred and Supplemental;
• Completion of the Comprehensive Clinical Examination;
• Completion of all Elective requirements; and
• Registration in the ACLS course with the ability to participate in the course and receive certification no later than the end of April of the academic year.

3.2 A prospective Spring Graduand List is organized early in the academic year and maintained throughout the academic year to identify the names of students who will be put forward for Convocation. The procedures section of this document outlines the Prospective Spring Graduand List process.

3.3 The Progress Committee and College Executive Council are the responsible governing bodies within the Max Rady College of Medicine which approve the Final Spring Graduand List.

3.4 The Assoc. Dean of the Max Rady College of Medicine is responsible for submitting the Final Spring Graduand List to Senate.

REQUIREMENTS FOR JULY 1 RESIDENCY

3.5 A Year IV student is permitted to begin Residency on July 1 if the student meets the following requirements by the end of the third week of June of each academic year:

• Completion of all Remediation;
• Completion of all NBME Examinations – Deferred and Supplemental;
• Completion of the Comprehensive Clinical Examination;
• Completion of all Electives requirements, and
• Registration in the ACLS course with the ability to participate in the course and receive certification before the third week of June of each academic year.

FALL CONVOCATION

3.6 A Year IV student’s name is sent forward for Convocation if the student meets the following requirements by September 15 of the academic year:

• Completion of all Remediation;
• Completion of all NBME Examinations – Deferred and Supplemental;
• Completion of the Comprehensive Clinical Examination;
• Completion of all Electives requirements, and
• Registration in the ACLS course with the ability to participate in the course and receive certification by end of April of the academic year.

3.7 A Prospective Fall Graduand List is organized from student names moved from the Prospective Spring Graduand List.

3.8 The Progress Committee and College Executive Council are the governing bodies within the Max Rady College of Medicine that approve the Final Fall Graduand List.

3.9 The Dean of the Max Rady College of Medicine is responsible for submitting the Final Fall Graduand List to Senate.

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4. PROCEDURES

RESPONSIBILITIES OF THE STUDENT

4.1 Know and understand the graduation requirements.

4.2 Ensure that all graduation requirements are met by the dates outlined within this policy.

4.3 Declare your intention to graduate using Aurora Student’s “Declarations” function. The deadline date for declaring an intention to graduate is mid-January of the year you intend on graduating. Students will receive an automated notice via their University of Manitoba email address.

SPRING CONVOCATION

UGME/STUDENT AFFAIRS, FACULTY, AND STAFF

4.4 In September of the academic year, the Administrator of Enrolment prepares a list of Year IV students, ensuring all names are organized by legal name. This list becomes the basis for the Prospective Spring Graduand List.

4.5 In October of the academic year, the Administrator of Enrolment organizes a meeting involving the Administrator of Evaluation Clerkship, Administrator of Clerkship, Administrator of Electives, and Business Manager, UGME to review the Prospective Spring Graduand List.

4.6 From October to March, the Administrator of Enrolment maintains and adjusts the Prospective Spring Graduand List and Prospective Fall Graduand List based on information submitted by the Administrator of Clerkship Evaluation, Administrator of Clerkship, Administrator of Electives, and Business Manager, UGME.

4.7 From April 1 to the date of the scheduled College Executive Council session in early to mid-April, identified UGME support staff work with students, departments, and outside agencies to confirm all graduation requirements are met for each student listed on the Prospective Spring Graduand List.

4.8 By the date of the College Executive Council session in early to mid-April of the academic year, the Administrator of Enrolment will organize a meeting involving the Administrator of Evaluations Clerkship, Administrator of Clerkship, Administrator of Electives, Business Manager, UGME, to create the Final Spring Graduand List from the Prospective Spring Graduand List. Student names from the Prospective Spring Graduand List that are not moved to the Final Spring Graduand List will be transferred to the Prospective Fall Graduand List.

4.9 Based on the information gathered from the April meeting, the Administrator of Enrolment will prepare two (2) letters as follows:

• Letter One - A letter promulgating the Final Spring Graduand List identifying students by legal name(s) and student number; and
• Letter Two - A letter promulgating the Final Spring Graduand List with student numbers only.

4.10 The Administrator of Enrolment, and Business Manager, UGME will have both letters approved by the Director of Evaluations and then signed by both the Director of Evaluations and Associate Dean of UGME.

4.11 The Director of Evaluations will subsequently present Letter Two, the Final Spring Graduand List with student numbers only to Progress Committee in its regular April session and then to College Executive Council during their scheduled early or mid-April session for approval.

4:12 Once approved by the College Executive Council, the Dea of the Max Rady College of Medicine will sign Letter One containing the Final Spring Graduand List to the Registrar’s Office by the deadline established within the current academic calendar.

4.13 The Administrator of Enrolment will send a copy of the Final Spring Graduand List to the Director of External Relations Faculty of Health Sciences for publication and a copy to the Convocation Coordinator, Registrar’s Office.

FALL CONVOCATION

REQUIREMENTS FOR JULY 1 RESIDENCY UGME/STUDENT AFFAIRS, FACULTY AND STAFF

4.14 From June 15 to June 20, UGME support staff will work with students, departments, and outside agencies to confirm all graduation requirements for each student listed on the Prospective Fall Graduand List who is accepted for a July 1 Residency program are met.

4.15 By June 21 of the academic year, the Administrator of Enrolment will organize a meeting involving the Administrator of Evaluations Clerkship, Administrator of Clerkship, Administrator of Electives, and the Business Manager, UGME to review the Prospective Fall Graduand List.

4.16 The Administrator of Enrolment will send a letter to the respective Residency program confirming that the student has met the graduation requirements for Fall Convocation.

FALL CONVOCATION

4.17 From September 15 to September 21, UGME support staff will work with students, departments, and outside agencies to confirm all graduation requirements are met for each student listed on the Prospective Fall Graduand List.

4.18 By September 22 of the academic year, the Administrator of Enrolment will organize a meeting involving the Administrator of Evaluations Clerkship, Administrator of Clerkship, Administrator of Electives, and Business Manager, UGME to review the Prospective Fall Graduand List

4.19 Based on the information gathered from the September meeting, the Administrator of Enrolment prepares two letters:

• Letter One - A letter establishing the Final Fall Graduand List identifying students’ legal name(s) and student number; and
• Letter Two - A letter establishing the Final Fall Graduand List with student numbers only.

4.20 The Administrator of Enrolment, and Business Manager, UGME will have both letters approved by the Director of Evaluations and then signed by both the Director of Evaluations and Associate Dean of UGME.

4.21 The Director of Evaluations presents Letter Two, the Final Fall Graduand List with student numbers only to Progress Committee during the September sitting and then to the College Executive Council during the scheduled September session for approval.

4.22 Once approved by the College Executive Council, the Dean of the Max Rady College of Medicine will sign Letter One containing the Final Fall Graduand List to the Registrar’s Office by the deadline established within the current Academic Calendar.

4.23 The Administrator of Enrolment will send a copy of the Final Fall Graduand List to the Director of External Relations Faculty of Health Sciences for publication and a copy to the Convocation Coordinator, Registrar’s Office.

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5. REFERENCES

5.1 UGME Policy and Procedures - Supplemental Assessments

5.2 UGME Policy and Procedures - Promotion and Failure

5.3 UGME Policy and Procedures – Deferred Examinations

5.4 UGME Policy and Procedures – Remediation

5.5 UGME Policy and Procedures – Midpoint In-Training Evaluation and Final In-Training Evaluation preparation, Distribution and Completion, and Essential Clinical Presentation Preparation, Distribution, Audit, and Remediation

5.6 UGME Policy and Procedures – Examination Conduct

5.7 UGME Policy and Procedures – Invigilation of Examinations

5.8 UGME Policy and Procedures – Examination Results

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6. POLICY CONTACT

Director, Evaluations

Policy name	Medical Student Performance Report (MSPR)
Application and scope	Year I through Year IV Undergraduate Medical Education Students
Approved date	August 16, 2022
Review date	March 2022
Revised date	March 2027
Approved by	College Executive Council

1.0 PURPOSE

The MSPR is a record of a medical student’s assessment which provides a description of the history of the student’s progress throughout the UGME program. It documents the student‘s academic progress and notes any gaps, extensions, and failures.

The MSPR provides an accurate representation of the summative evaluative information for each student and is a comprehensive record of each student’s performance. Adhering to and fulfilling the specific requirements of the Canadian Resident Matching Service (CaRMS) application process, MSPRs are forwarded to CaRMS with a copy being placed in the student’s active file. For future reference and verification, a finalized copy of the MSPR is updated for each student upon graduation and placed within each student’s permanent academic record.

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2.0 DEFINITIONS

2.1 CaRMS – Canadian Resident Matching Service

2.2 MSPR – Medical Student Performance Record

2.3 Final In-Training Evaluation Report (FITER) - A comprehensive summary of student performance as a necessary component of their Clerkship training which demonstrates the full range of competencies (knowledge, skills, and attitudes) required of a physician. Electronically distributed at the start of each rotation, FITERs must be completed and submitted electronically at the end of the rotation. This must include a narrative description of medical student performance

2.4 National Board of Medical Examiners (NBME) Examination – A multiple-choice examination developed by the NBME that is administered at the end of the Surgery, Internal Medicine, Obstetrics/Gynecology and Reproductive Sciences, Pediatrics, Family Medicine, and Psychiatry clinical rotations at the Clerkship level of the UGME program.

2.5 Course - An educational unit, which covers a single topic or a small section of broad topics that are studied for a given period of time, and counts towards the completion of the M.D.

2.6 Objective Structured Clinical Examination (OSCE-type) – an examination used to assess the clinical skills of students.

2.7 Comprehensive Clinical Exam (CCE) – An objective structured clinical-type

2.8 examination used to assess the clinical skills of students in Clerkship.

2.9 UGME – Undergraduate Medical Education.

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3.0 POLICY STATEMENTS

3.1 The MSPR for each graduating student will include information on each of the following areas:

• Student identification
• Events worthy of particular note
• Academic history
• Academic progress
• Summary
• Signature of Associate Dean, UGME

3.2 The MSPR will be electronically created, reviewed, and submitted to CaRMS by the stated deadline in each academic year.

3.3 The MSPR will be updated following CaRMS submission to include new information related to academic progress in the final months of the UGME program.

3.4 The MSPR will identify the following information in the Academic History section of the Max Rady College of Medicine’s Promotion and Failure Policy.

3.5 The Associate Dean, UGME maintains the right to change narrative FITER information on individual MSPRs as necessary.

3.6 Support staff has no authority to change the intent of narrative FITER information.

3.7 The MSPR, prepared for submissions to CaRMS, will contain narrative FITER information for early electives completed during summer vacation periods.

3.8 The MSPR, prepared for submissions to CaRMS, will not contain narrative FITER information for electives confirmed from early October to the deadline for CaRMS submission

3.9 The MSPR, as an institutional assessment, is considered a component of a student’s academic record and, thus, will be made available for student review. Students will be permitted to correct factual errors in the MSPR, but not to revise evaluative statements contained within the MSPR. Students are encouraged, when required, to engage Student Affairs in supporting advocacy efforts in addressing perceived MSPR discrepancies.

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4.0 PROCEDURES

RESPONSIBILITIES OF STUDENTS

4.1 Track examination results (Pass/Fail) and remediation information to ensure that information matches what is included in the MSPR if applicable.

4.2 Complete required FITER, ECP, and rotation evaluations electronically at the end of each rotation to ensure FITER comments are released for inclusion in the MSPR.

4.3 Review section one, section two and section three of the MSPR information provided by Evaluation personnel to ensure it accurately reflect requisite information.

4.4 Correspond with Evaluation personnel with respect to section one, section two, and section three of MSPR as necessary and within the stated deadlines.

4.5 Arrange and attend meetings with the Max Rady College of Medicine, and Student Affairs staff to review MSPRs as required in the event that advocacy on specific issues of concern is required.

4.6 Advise students of the process to request/order University transcripts to be submitted to the CaRMS Document Centre by the student following promotion to Year 4.

4.7 Advise Evaluation personnel of the decision to decline participation in the CaRMS match for graduation year prior to the CaRMS submission deadline.

RESPONSIBILITIES OF UGME SUPPORT STAFF: November

Administrator, Clerkship Evaluation

4.8 Communicate with Research Office to receive all required information on students who completed the B.Sc. (Med) program in the format outlined for MSPR merging.

4.9 Ensure the generic MSPR communications are working effectively such that MSPR information may be dispatched to students.

MSPR Section 1 - December to mid-January

Administrator, Clerkship Evaluation

4.10 Organize the MSPR Section one template to accommodate:

CaRMS submission date

Merged fields for:

• Student legal name
• Identifying information
• Events worthy of particular note under the headings:
  • Leadership
  • Awards
  • Research
• Academic History:
  • Date of expected graduation
  • Date of initial registration in UGME
  • Joint degree(s)

4.11 Prepare instructions for student completion of MSPR section one.

4.12 Identify students who have been carried over from the previous year such that they may be included in the listing for the present class for all components of the MSPR.

4.13 Create and electronically file individual student MSPR section one from the merged document.

Late January

Administrator, Clerkship Evaluation

4.14 Email MSPR section one to each Year 3 student with instructions on how to complete the document as well as the expected deadline for return.

February through March

Administrator, Clerkship Evaluation and Administrator, Pre-Clerkship Evaluation & OSCE- Type Examinations

4.15 Review each MSPR section one for errors and/or omissions. Confer with the Associate Dean of UGME on concerns related to “Events Worthy of Particular Note”.

4.16 Communicate with individual students if clarification or further information for MSPR section one is required.

4.17 Confirm that MSPR section one is up-to-date for all Year 3 students.

MSPR Section 1 and 2

April to mid-May

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.18 Ensure all period one (1) to period four (4) FITERs are completed and have been submitted to the curriculum management system.

4.19 Prepare a listing of students who have not completed the student FITER, ECP, and Rotation Evaluation requirements for period one (1) to period four (4).

4.20 Communicate with each student who has not completed the FITER, ECP, and Rotation Evaluation requirements for period one (1) to period four (4) to have these requirements met by the end of April.

4.21 Run the MSPR Report in the curriculum management system (Entrada) for period one (1) to period four (4) and export as an MS Excel file.

4.22 Modify exported MS Excel files to align with required fields for the MSPR.

4.23 Complete a spell check of the modified MS Excel file.

4.24 Communicate with the Administrator, Electives to receive Early Exposure data in the format required for the MSPR section two.

4.25 Incorporate Early Exposure data into the modified MS Excel file.

4.26 Electronically transfer (“merge”) MS Excel file data into the MSPR section two of the MS Word template.

4.27 Create individual electronic student MSPR section two files for each student in MS Word.

4.28 Save each MS Word document as a PDF file to maintain the integrity of the information.

4.29 Prepare instructions for student completion of combined MSPR sections one and two.

Late May

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.30 E-mail MSPR combined sections one and two PDF document to each Year 3 student, who has completed the FITER, ECP, and Rotation Evaluation requirements, with instructions on how to complete the document and the deadline for return.

4.31 Contact each student with outstanding FITER, ECP, and Rotation Evaluation requirements informing the student that the combined sections one and two will be released for review when the requirements are met.

Late June to mid-July

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.32 Make changes to individual MSPR section two files based on student feedback.

4.33 Confirm that section two is up-to-date for all students.

MSPR Section 1 and Section 2 Integration

Late July to mid-August

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.34 Confirm that each student has met the FITER, ECP, and Rotation Evaluation requirements for section two and has reviewed section two of the MSPR.

4.35 Combine MSPR section two and MSPR section one for each student, saving each file in MS Word and PDF format.

4.36 Prepare instructions for student review of MSPR section one and section two.

Late August

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.37 E-mail composite MSPR section one and section two PDF document to each Year

3 student with instructions on how to review the document and the deadline for return.

Early September

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.38 Make changes to composite MSPR section one and section two based on student feedback

4.39 Confirm that composite section one and section two are complete for all students.

Mid-September

Administrator, Clerkship Evaluation

4.40 Email Med 4 students with instructions related to the application for transcripts for submission to CaRMS from the University of Manitoba’s Transcript office.

Mid to late September

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.41 Ensure all period five (5) to period seven (7) FITERs are completed electronically.

4.42 Prepare a listing of students who have not completed the FITER, ECP, and

Rotation Evaluation requirements for period five (5) to period seven (7).

4.43 Communicate with each student who has not completed the FITER, ECP, and Rotation Evaluation requirements for period five (5) to period seven (7) to have these requirements met by a specific deadline.

4.44 Ensure the UGME MS Excel file containing student NBME examination results is up-to-date.

4.45 Communicate with the Administrator, Electives to receive electives data in the format required for MSPR section three.

4.46 Organize PDF files on the s:\drive for viewing by the Max Rady College of Medicine’s Student Affairs personnel in preparation for the student meetings.

4.47 Inform the Max Rady College of Medicine’s Student Affairs personnel of the location of student files.

Mid October

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.48 Communicate with all Year 4 students to complete the FITER, ECP, and Rotation Evaluation requirements for period five (5) to period eight (8) in order to receive composite MSPR sections one, two, and three for review in a timely manner.

4.49 Ensure all period eight (8) FITERs are completed electronically.

4.50 Remind students to complete their FITER, ECP, and Rotation Evaluation requirements for period five (5) to period eight (8) in order to receive the composite sections of the MSPR.

4.51 Run the MSPR Report in the Curriculum Management System (Entrada) for period five (5) to period eight (8) and export it as an MS Excel file.

4.52 Complete a spell check of the cleansed MS Excel file.

4.53 Incorporate the NBME Examination data and Electives data into the cleansed MS Excel file.

4.54 Electronically transfer (“merge”) MS Excel file data into composite MSPR sections one, two, and three MS Word template.

4.55 Create individual electronic student composite MSPRs sections one, two, and three files for each student in MS Word.

4.56 Save each MS Word document as a PDF file to maintain the integrity of the information.

4.57 Prepare instructions for student review of composite MSPR.

End October

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.58 E-mail composite MSPR sections one, two, and three PDF documents to each Year 4 student, with instructions on how to review the document and the deadline for return.

4.59 Contact each student with outstanding FITER, ECP, and Rotation Evaluation requirements informing the student that Section Three will be released for review when the requirements are met.

4.60 Update PDF files on the network drive for viewing by the Max Rady College of Medicine and Student Affairs staff in preparation for student meetings.

4.61 Inform the Max Rady College of Medicine, and Student Affairs personnel of the location of student files.

Early November

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.62 Make changes to composite MSPR sections one, two, and three based on student feedback.

4.63 Insert the following components of Academic History into the final MS Word document for each student:

• Leaves of absence/gaps in an educational program.
• Student required to remediate and failures during Year 2, Year 3, or Year 4.
• Professionalism & disciplinary actions.

4.64 Save each completed MS Word document as a PDF file.

4.65 E-mail the complete MSPR PDF document to each Year 4 student with instructions on how to review the document and advise of the deadline for minor changes.

Mid-November

Administrator, Clerkship Evaluation and Office Assistant, UGME

4.66 Make minor changes to MSPR as identified by students.

4.67 Provide MSPR files to Associate Dean, UGME for review and approval.

4.68 Once approved, insert the Associate Dean’s electronic signature into each completed MSPR.

4.69 Save each MS Word document as a PDF file to maintain the integrity of the information.

4.70 Send the completed MSPR (PDF file) to each student for the student’s personal file.

4.71 Send each completed MSPR electronically to CaRMS on or before the CaRMS deadline.

Associate Dean, UGME

4.72 Resolve issues related to content in individual student MSPRs throughout the completion process.

4.73 Review all finalized MSPRs before the electronic signature is applied to each file.

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5.0 REFERENCES

5.1 Association of American Medical Colleges document “A Guide to the Preparation of the Medical Student Performance Evaluation”

5.2 UGME – Promotion and Failure Policy and Procedures

5.3 UGME - Midpoint In-Training Evaluation & Final In-Training Evaluation Preparation, Distribution and Completion and Essential Clinical Presentation Preparation, Distribution, Audit, and Remediation

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6.0 POLICY CONTACT

Administrator of Clerkship Evaluation

Policy name	Student records
Application and scope	Faculty, staff and year I to year IV undergraduate medical education students
Approved date	April 2017
Review date	January 2021
Revised date
Approved by	College Executive Council

1. PURPOSE

This policy and related procedures pertain to the creation, management and storage of all records for those who apply and/or admitted to the Undergraduate Medical Education program. This policy does not deal with information stored by offices such as the Office of Student Affairs, Medicine and Office of Disability Services, University of Manitoba. Faculty and staff notes and emails to and from applicants and students are not part of Student Records.

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2. DEFINITIONS

2.1 Application File – that of a person currently applying or admitted to the Undergraduate Medical Education program. Appendix 1 contains Information on the types of documents included in such a record.

2.2 Active File – that of a student who is currently enrolled in the Undergraduate Medical Education program or on an approved leave of absence. Appendix 2 contains Information on the types of documents included in such a record.

2.3 Permanent File – that of a student who is no longer enrolled in the Undergraduate Medical Education program due to graduation, dismissal, withdrawal, or death. Appendix 1 contains Information on the types of documents included in such a record.

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3. POLICY STATEMENTS

3.1 The Administrator, Enrolment is the custodian of all Student Records.

3.2 Student Records are created as follows:

• Application File – when an applicant submits the first of the required application documents.
• Active File - when a student is admitted to the Undergraduate Medical Education program.
• Permanent File – when a student graduates, is dismissed, withdraws, or dies.

3.3 All Student Records are securely stored either within the Educational Programs Office or off-site. See Appendix 1.

3.4 The student can view information in his/her Active File upon request.

3.5 The student cannot view information in the Application File.

3.6 Faculty and staff can view information in the Application and Active Files on a need to know basis.

3.7 The student may request copies of evaluation documents within the Active File for academic purposes.

3.8 Faculty and staff can view information in the Permanent Files stored within the Office of the Dean, on a need to know basis.

3.9 Faculty and staff access to Permanent Files stored off-site requires the approval of the Administrator, Enrolment.

3.10 No documentation from Student Records can be removed from the Educational Programs Office, Max Rady College of Medicine.

3.11 All documentation from the Application and Active Files that is not required for the Permanent File is securely destroyed when the Permanent File is created.

3.12 A student can challenge the contents of the Active File by following the process outlined in the Undergraduate Medical Education Student Appeals Committee Policy and Procedures.

3.13 This policy will be reviewed on the first anniversary of its original passage and every three years thereafter.

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4. PROCEDURES

4.1 Admissions personnel create the Application File for each person applying to the Undergraduate Medical Education program upon receipt of the first Application document. See Appendix 2 for Components of the Application File.

4.2 Enrolment Services personnel create the Active Record for each person who accepts an Offer of Admission to the Undergraduate Medical Education program. See Appendix 1 for Components of the Application File.

4.3 A student requesting to view the Active File contacts the Administrator, Enrolment to set an appointment. This request will ordinarily be accommodated within 2 working days.

4.4 Evaluation personnel place the following pieces of information in Active Files in accordance with the timelines stated:

• All Pre-Clerkship evaluation information i.e. student results, letter of probationary/monitored status and Clerkship NBME information within 10 working days following the distribution of this information to students.
• Letters related to examination deferral, supplementary examinations, etc. within 3 days of receipt of such information.

4.5 Any UGME support staff member who receives document(s) intended for the Active File must ensure such information is placed in the record within 3 working days of receipt of the document(s).

4.6 Enrolment Services personnel create the Permanent File upon a student's graduation, dismissal, withdrawal, or death. See Appendix 2 for Components of the Permanent File.

Components of Student Records - Appendix 2

Documentation Related to Student Records		Components of Student Records
		Application File		Active File		Permanent File
		Yes	No	Yes	No	Yes	No
1.	Max Rady College of Medicine Application including documentation for scoring rurality			√		√
2.	Medical College Admission Test (MCAT) Scores			√		√
3.	Letters of Reference	√					√
4.	Transcript from Undergraduate/Pre-Medical coursework which identifies GPA			√			√
5.	Documentation for applicants selected for interviewing including:
	• MMI Statement of Confidentiality	√				√
	• MMI Scoring	√				√
	• Adult Child Abuse Registry Self-Declaration Form for Applicants to Admission			√		√
6.	Self-Declaration of Academic Discipline			√		√
7.	Self-Declaration re. Criminal Record			√
8.	Letters of response to Application			√			√
9.	Letter of Admission to Undergraduate Medical Education Program			√		√
10.	Confirmation that Child Abuse and Criminal Record are up to date			√			√
11.	Acknowledgement Form related to Technical Standards Document and Accommodation Policy			√			√
12.	Consent and Waiver Form			√			√
13.	Annual confirmation of CPR			√			√
14.	Student Record Update			√			√
15.	Pre-Clerkship Student Evaluation Summary for each Block (Including letters of Probationary/Monitored Status as required)			√			√
16.	Summary of OSCE-type results (Including letters of Probationary/Monitored Status as required)			√			√
17.	Summary of National Board of Medical Examiners (NBME) results for each required core Clerkship rotation(Including letters of Probationary/Monitored Status as required)			√			√
18.	Notices of awards, research abstracts, publications			√		√
19.	Appeal/legal documentation			√		√
20.	Documentation related to:
	• Academic failure			√			√
	• Undergraduate Medical Education Policies i.e. Attendance, Immunization, etc.			√			√
	• Professionalism and conduct			√		√
	• Accommodations in place for student			√			√
	• Leaves of absence			√		√
	• Appreciation from patients, commendations from faculty			√			√
	• Examination deferrals, supplementary examinations			√			√
21.	Letters prepared in relation to verification of good standing or enrolment in the program			√
22.	Copy of official transcripts			√		√
23.	Completed Medical Student Performance Report			√		√
24.	Documentation of dismissal or withdrawal			√		√
25.	Obituary				√	√
26.	Verification of training to licensing authorities				√	√

1. Purpose and mandate

1.1. Purpose/Mandate: The Admissions Committee (“Committee”) of the Max Rady College of Medicine (“College”), Rady Faculty of Health Sciences (“RFHS”) is established to oversee all aspects of, and to recommend policies and procedures respecting, the admission of students to the undergraduate medical education (“UGME”) program, leading to the MD degree, to the College.

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2. Reporting and accountability

2.1. Accountability: The Committee is a standing committee of the College Council/College Executive Council, Max Rady College of Medicine.

2.2. Reporting: The Committee, through the Chair, shall report to the College Council/College Executive Council.

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3. Chairperson and committee membership

3.1. Chair:  The Chair of the Committee shall be the Associate Dean, Admissions, Max Rady College of Medicine or designate. The Chair is responsible for the following at Committee meetings:

(a) Calling the meeting to order,

(b) Establishing an agenda and ensuring agenda items are addressed,

(c) Ensuring the minutes from prior meeting(s) are reviewed and approved by the Committee (with or without modification),

(d) Facilitating discussion to reach consensus on matters under consideration in a professional manner.

(e) Adjourning meetings after business is concluded, and

(f) Acting as the main representative of the Committee.

3.2. Membership:  The Committee membership shall then consist of the following members, including the Chair or designate:

(a) The Associate Dean, UGME or designate,

(b) The Associate Dean, Professionalism or designate,

(c) The Executive Director, Indigenous Academic Affairs, Ongomiizwin or designate,

(d) The Medical Director, Manitoba Healthcare Providers Network,

(e) The Chair, Canadian Indigenous Interview Panel,

(f) The Educational Director, Bilingual Stream,

(g) Two faculty representatives, with knowledge in social accountability,

(h) Three faculty members, one of whom shall have a primary appointment in a Basic Medical Science department,

(i) One student representative, executive member of the Manitoba Medical Student Association or designate,

(j) One student representative, non-executive member of the Manitoba Medical Student Association or designate,

(k) The Executive Director, Enrolment Services or designate

(l) The Director, Equity, Diversity and Inclusion, Rady Faculty of Health Sciences (non-voting),

(m) The Anti-Racism Practice Lead, Rady Faculty of Health Sciences or designate (non-voting),

(n) The Admissions Officer, Undergraduate Admissions, Enrolment Services, assigned to the Max Rady College of Medicine (non-voting),

(o) The Senior Lead, Indigenous Health Student Affairs Ongomiizwin Education, Rady Faculty of Health Sciences, or designate (non-voting),

(p) The Data Analyst, Admissions (non-voting),

(q) The Business Manager, UGME (non-voting),

(r) The Admissions Assessment Lead (non-voting),

(s) The Administrator, Admissions (non-voting),

(t) The Admissions Advisor (MMI), Admissions (non-voting),

(u) The Admissions Advisor (Indigenous Panel), Admissions (non-voting),

(v) The Committee Administrator (non-voting).

3.3. Equitable, Inclusive and Diverse Membership: The College strives to achieve equitable, inclusive, and diverse membership on its committees that is reflective of its commitment to equity, diversity, and inclusion and this should be considered in the appointment of Committee members.

3.4. Liaisons: Committee members shall serve as liaison persons with others in the areas from which they are appointed.

3.5. Best Interests: Committee members shall deal with matters before the Committee in such a way that the best interests of the College take precedence over the interests of any of its constituent parts, should those interests conflict or appear to conflict.  

3.6. Consultation: In carrying out its role, the Committee may call upon various resources as it deems required.

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4. Term of office

4.1.    The term of office of each Committee member shall be until the first of the following occurs:

(a) the individual no longer holds the position noted in 3.2,

(b) the term of the appointment ends,

(c) the appointment is rescinded by the appointer, or

(d) the individual resigns from the Committee.

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5. Functions and activities of committee

5.1. As part of its Mandate, the Committee will engage in the following activities:  

• Recommending on all aspects of the eligibility requirements for applicants seeking admission to studies leading to the MD degree,
• Recommending on all aspects of the process for selection of applicants for admission to studies leading to MD degree, including the criteria for selection,
• Selecting from among the eligible applications those whom an offer of admission shall be made, in accordance with developed and approved guidelines and criteria of the College Council/College Executive Council and the University of Manitoba/Senate,
• Determining if a particular offer of admission shall be rescinded, where, after an offer is made, information comes to the attention of the Committee that calls into question the applicant’s character or integrity, including without limitation, dishonesty or fraud in the application process or other unprofessional behaviour that would have precluded an offer of admission,
• Exercising its discretion in determining matters relating to the admission of students to studies leading to the MD degree, when not explicitly covered by the rules and regulations of the Max Rady College of Medicine, the Senate, or otherwise within the University rules and regulations,
• Regular reporting on its activities and providing recommendations for approval to the appropriate approval bodies, as required, and
• The Committee may refer priority issues connected to its Mandate that require review, collaboration and analysis to Committee subcommittees or working groups.

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6. Meetings

6.1. Number of Meetings: The Committee shall meet at least six (6) times per year, and additional meetings at the call of the Chair or Chair designate.

6.2. Notice of Meetings: Notice of a Committee meeting should be provided to Committee members, at least five (5) business days advance of the meeting, unless waived by the Committee members at the meeting.

6.3. Agenda: Agenda items should be sent to the Committee secretary at least 48 hours in advance of the meeting.  The agenda should be prepared and distributed to the members of the Committee prior to the meeting.

6.4. Quorum: A simple majority of the voting members of the Committee shall constitute a quorum. Faculty members must constitute the majority of voting members present at all meetings, in accordance with CACMS Standard 10.  

6.5. Decision-Making: The preferred model for decision-making is consensus.  If consensus cannot be reached, the varying recommendations may be taken to a vote.  The Chair or Chair designate shall only vote in the case of a tie.

6.6. Committee Meeting Guests: All Committee meetings will be limited to members only unless the Chair or Chair designate otherwise grants approval for certain individuals to attend all or a portion of the meeting.

6.7. Telephone Meetings and Email Discussion:  The Chair or Chair designate may consult with Committee members by email or arrange telephone meetings, instead of in-person meetings, as the circumstances may require.

6.8. Confidentiality: All Committee members, resource persons, consultants, guests, and administrative support persons who may be in attendance at a Committee meeting or privy to Committee information, are required to protect and keep confidential any protected information (e.g., classified or privileged information) received through participation on the Committee, unless such information is otherwise approved for public information.

6.9. Minutes & Confidentiality: Minutes are to be taken of business occurring during Committee meetings.  However, the Committee may move “in camera” to deal with certain items if the subject matter being considered relates to personal and confidential matters that are exempt from disclosure under applicable access and privacy legislation.  Once approved by the Committee, meeting minutes shall be publicly available, in accordance with applicable legislation.  

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7. Committee administrative support

7.1. The Committee shall receive administrative support from the College.  The administrative support shall be provided through an individual whose duties shall include:

a) Assisting the Chair or Chair designate with preparation of Committee meeting agendas and distributing notification of meetings,

b) Ensuring follow-up of Committee action items,

c) Information gathering,

d) Preparation and distribution of meeting material,

e) Minute-taking, and

f) Maintaining Committee records.

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8. Subcommittees

8.1. Standing Subcommittees: The Committee has the following standing subcommittees (“Subcommittees”) that report to the Committee:

8.1.1. Professionalism Subcommittee on Admissions

8.1.2. MMI Question Selection Subcommittee

8.1.3. Transfer Subcommittee

8.1.4. General Appeal Subcommittee

8.1.5. Professionalism Appeal Subcommittee

8.1.6. Indigenous Appeal Subcommittee

8.1.7. Indigenous Panel Selection Subcommittee

8.1.8. Indigenous Panel Advisory Subcommittee

8.1.9. Academic Attribute Subcommittee

8.1.10. Non-Academic Attribute Subcommittee

8.1.11.    Strategic Selection Subcommittee

Each subcommittee shall have its own terms of reference that sets out its mandate, which terms of reference shall be approved by the Committee.

8.2. Subcommittee Reports:  A report from its subcommittees shall be a standing item on the Committee meeting agenda.

8.3. Referral to Subcommittees:  The Committee may refer issues of priority to one or more Subcommittees as the circumstances require.

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9. Amendments to terms of reference

9.1. Amendments to these Terms of Reference may be proposed by the Committee to the College Council/College Executive Council for approval. 

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10. Dates of approval, review and revision

10.1. Date approved: College Executive Council – October 1, 2024

10.2. Review: Formal review of these terms will be conducted every five (5) years.  In the interim these terms may be revised or rescinded if the Committee deems necessary.

10.3. Supersedes: Admissions Committee – Terms of Reference (December 19, 2023; December 22, 2021; November 17, 2020; March 27, 2019; September 25, 2018; February 15, 2011)

10.4. Committee Contact:  Administrator, Admissions, Max Rady College of Medicine

10.5. Effect on Previous Statements:  These terms shall supersede all previous College terms on the subject matter herein.

1. PURPOSE AND MANDATE

1.1. Purpose/Mandate: The Canadian Indigenous Panel Advisory Subcommittee (“Subcommittee”) is a subcommittee of the Admissions Committee (“Committee”), Max Rady College of Medicine (“College”), Rady Faculty of Health Sciences (“RFHS”), mandated by the Admissions Committee to provide advice and direction regarding the format of the Canadian Indigenous Panel Interviews (“Panel Interview”), the development of the Panel Interview questions, and the criteria used in the selection of successful applicants from the Canadian Indigenous Application Pool (“Indigenous Pool”) (its “Mandate”).

2. REPORTING AND ACCOUNTABILITY

2.1. Accountability: The Subcommittee is a subcommittee of, and reports to, the Committee.

2.2. Reporting: The Subcommittee, through the Chair, shall annually report to the Chair of the Committee.

3. CHAIRPERSON AND SUBCOMMITTEE MEMBERSHIP

3.1. Chair: The Chair of the Subcommittee shall be the Associate Dean, Admissions, of the College. The Chair is responsible for the following at Subcommittee meetings:

a) Calling the meeting to order,

b) Establishing an agenda and ensuring agenda items are addressed,

c) Ensuring the minutes from prior meeting(s) are reviewed and approved by the Committee (with or without modification),

d) Facilitating discussion to reach consensus on matters under consideration in a professional manner, e) Adjourning meetings after business is concluded, and

f) Acting as the main representative of the Subcommittee.

3.2. Membership: The Subcommittee membership shall then consist of the following members, including the Chair:

(a) Executive Director, Indigenous Academic Affairs, Ongomiizwin, (b) Chair, Canadian Indigenous Panel,

(c) Elders and Knowledge Keepers,

(d) Three (3) Indigenous student representatives selected by the Chair,

(e) Four (4) community members selected by the Chair,

(f) Three (3) members selected by the Chair for their previous experience as Panel interviewers,

(g) The Senior Lead, Indigenous Health Student Affairs Ongomiizwin Education, Rady Faculty of Health Sciences,

(h) The Administrator, Admissions, College (non-voting),

(i) The Admissions Advisor, Admissions, College (non-voting), and

(j) The Subcommittee Administrative Support (non-voting).

Designates/alternates will be allowed. The number of members for the Subcommittee may fluctuate to accommodate changes in the format of the Panel Interview and number of questions required each year. Additional representation may be added at the discretion of the Chair of the Subcommittee in consultation with the Administrator, Admissions.

3.3. Equitable, Inclusive and Diverse Membership: The College strives to achieve equitable, inclusive and diverse membership on its committees that is reflective of its commitment to equity, diversity and inclusion and this should be considered in the appointment of Subcommittee members.

3.4. Best Interests: Subcommittee members shall deal with matters before the Subcommittee in such a way that the best interests of the College take precedence over the interests of any of its constituent parts, should those interests conflict or appear to conflict.

3.5. Consultation: In carrying out its role, the Subcommittee may call upon various resources as it deems required.

4. TERM OF OFFICE

The term of office of each Subcommittee member shall be until the first of the following occurs: (a) the individual no longer holds the position noted in 3.2;

(b) the term of the appointment ends;

(c) the appointment is rescinded by the appointer; or

(d) the individual resigns from the Subcommittee.

5. FUNCTIONS AND ACTIVITIES OF SUBCOMMITTEE

5.1. As part of its Mandate, the Subcommittee will engage in the following activities at the meetings:

(a) Evaluate Panel Interview Format: The Subcommittee will evaluate and provide guidance to modify and update the Panel Interview format as the needs of the applicants and College changes.

(b) Determine Interview Question and Autobiographical Sketch Content: The Subcommittee will determine the content of the Panel Interview questions and autobiographical sketch to ensure they represent the attributes required of Indigenous physicians in the community.

(c) Establish Selection Criteria: The Subcommittee will establish the criteria and guidelines in which applicants are selected for an offer through the Indigenous Pool.

(d) Reporting: The Subcommittee will present their decisions to the Committee.

6. MEETINGS

6.1. Number of Meetings: The Subcommittee shall meet at least two (2) times per year, and additional meetings at the call of the Chair.

6.2. Notice of Meetings: Notice of a Subcommittee meeting should be provided to Subcommittee members, at least ten (10) business days advance of the meeting, unless waived by the Subcommittee members at the meeting.

6.3. Agenda: Agenda items should be sent to the Subcommittee Administrative Support person at least 48 hours in advance of the meeting. The agenda should be prepared and distributed to the members of the Subcommittee prior to the meeting.

6.4. Quorum: A simple majority of the members of the Subcommittee shall constitute a quorum.

6.5. Decision-Making: The preferred model for decision-making is consensus. If consensus cannot be reached, the varying recommendations may be taken to a vote. The Chair of a Subcommittee will not vote except in the event of a tie.

6.6. Subcommittee Meeting Guests: All Subcommittee meetings will be limited to members only unless the Chair otherwise grants approval for certain individuals to attend all or a portion of the meeting.

6.7. Electronic or Telephone Meetings and Email Discussion: The Chair may consult with Subcommittee panel members by email or arrange electronic or telephone meetings, instead of in-person meetings, as the circumstances may require.

6.8. Confidentiality: All Subcommittee members, resource persons, consultants, guests, and administrative support persons who may attend a Subcommittee meeting or privy to Subcommittee information, are required to protect and keep confidential any protected information (e.g., classified or privileged information) received through participation on the Subcommittee. Confidential and protected information includes, but is not limited to, the personal information of all applicants; the personal information of all individuals associated with the Panel Interview process, including their comments and opinions regarding the members, the applicants, and the process; as well as all interview questions, rubrics, selection criteria, deliberations, and other procedural documentation that has been classified as confidential and privileged.

6.9. Minutes & Confidentiality: Minutes are to be taken of business occurring during Subcommittee meetings.

However, the Subcommittee may move “in camera” to deal with certain items if the subject matter being considered relates to personal and confidential matters that are exempt from disclosure under applicable access and privacy legislation. Minutes taken during a panel meeting form part of the official record of the reconsideration.

7. SUBCOMMITTEE ADMINISTRATIVE SUPPORT

7.1. The Subcommittee shall receive administrative support from the College. The administrative support shall be provided through an individual whose duties shall include:

a) Assisting the Chair with preparation of Subcommittee meeting agendas and distributing notification of meetings.

b) Ensuring follow-up of Subcommittee action items.

c) Information gathering.

d) Preparation and distribution of meeting material.

e) Minute-taking; and

f) Maintaining Subcommittee records.

8. AMENDMENTS TO TERMS OF REFERENCE

8.1. Amendments to these Terms of Reference may be proposed by the Subcommittee to the Admissions

Committee for approval.

9. DATES OF APPROVAL, REVIEW AND REVISION

9.1. Date approved: Admissions Committee – January 26, 2022

9.2. Review: Formal review of these terms will be conducted every five (5) years. In the interim these terms may be revised or rescinded as the Subcommittee may recommend or as the Committee otherwise deems necessary.

9.3. Supersedes: N/A

9.4. Subcommittee Contact: Admissions Administrator, Admissions Office

9.5. Effect on Previous Statements: These terms shall supersede all previous College terms on the subject matter herein.

1. PURPOSE AND MANDATE

1.1. Purpose/Mandate: The Canadian Indigenous Panel Appeal Subcommittee (“Subcommittee”) of the Admissions Committee (“Committee”), Max Rady College of Medicine (“College”), Rady Faculty of Health Sciences (“RFHS”) is established in accordance with the Reconsideration of Admissions Decisions (Admissions Appeals) Policy and the Max Rady College of Medicine Applicant Bulletin, to reconsider a decision of the Committee of the College respecting applicants to the Undergraduate Medical Education (“UGME”) Program who applied under the Canadian Indigenous Applicant Pool (“Indigenous Pool”).

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2. REPORTING AND ACCOUNTABILITY

2.1. Accountability: The Subcommittee is established on an ad hoc basis at the call of the Chair of the Committee, to reconsider admissions decision as they relate to the Indigenous Pool, in accordance with this Terms of Reference and the Admissions Appeals Policy of the College.

2.2. Reporting: The Subcommittee, through the Chair, shall annually report to the Chair of the Committee, respecting the number, types of requests for reconsideration and outcomes determined by the Subcommittee, without comprising the confidentiality of the process.

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3. CHAIRPERSON AND SUBCOMMITTEE MEMBERSHIP

3.1. Chair: The Chair of the Subcommittee shall be appointed by the Chair, Admissions Committee. The Chair is responsible for the following at Review Panel meetings:

(a) Receiving and reviewing an applicant’s request for reconsideration, to determine whether it has jurisdiction, and whether there are grounds for reconsideration.

(b) Communicating with the applicant and Chair, Admissions Committee, respecting requests for reconsideration and any determinations.

(c) Calling the Subcommittee meeting(s) to order.

(d) Establishing an agenda and ensuring agenda items are addressed.

(e) If the meeting is a continuation of an ongoing reconsideration of decision hearing, ensuring the minutes from prior meeting(s) are reviewed and approved by the Committee (with or without modification).

(f) Facilitating discussion to reach consensus on matters under consideration in a professional manner.

(g) Adjourning meetings after business is concluded.

(h) Acting as the main representative of the Subcommittee. 

3.2. Subcommittee Membership: A panel of the Subcommittee will be constituted on an ad hoc basis, to reconsider admission decisions as required. The panel shall then consist of the following Indigenous members, including the Chair:

(a) Faculty Representative: One Indigenous faculty member of the Rady Faculty of Health Sciences.

(b) Student Representative: One Indigenous Med III or IV student representative.

(c) Panel Representative: One Indigenous individual with experience as an interviewer with the Canadian Indigenous Panel Interview.

(d) An Elder or Knowledge Keeper, Ongomiizwin.

All representatives appointed by the Chair, Admissions Committee.

3.3. Equitable, Inclusive and Diverse Membership: The College strives to achieve equitable, inclusive, and diverse membership on its committees that is reflective of its commitment to equity, diversity, and inclusion and this should be considered in the appointment of Subcommittee panel members.

3.4. Best Interests: Subcommittee panel members shall deal with matters before the Subcommittee in such a way that the best interests of the College take precedence over the interests of any of its constituent parts, should those interests conflict or appear to conflict.

3.5. Consultation: In carrying out its role, the Subcommittee may call upon various resources as it deems required.

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4. TERM OF OFFICE

4.1. The term of office of each Subcommittee panel member shall be for the duration of hearing and determining a reconsideration decision. The panel will be disbanded once a determination has been made.

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5. FUNCTIONS AND ACTIVITIES OF SUBCOMMITTEE

5.1. As part of its Mandate, the Subcommittee will engage in the following activities:

a. Receive Information: The Subcommittee will receive, for review, all documents related to the applicant’s request for reconsideration.

b. Determine Jurisdiction and Grounds: The Subcommittee Chair will determine if the appeal meets the established jurisdiction of the Subcommittee and whether there are grounds for reconsideration.

c. Request Information: The Subcommittee will request additional information, as required, from the Admissions Office.

d. Meet with the Applicant: The Subcommittee will meet with the applicant to hear their oral submissions, along with a student advocate or other support person, if desired, as well as any other individuals deemed necessary.

e. Decision-Making: The Subcommittee will deliberate and take a vote, in camera, regarding the request for reconsideration.

f. Reporting: The Subcommittee will present their decisions to the Committee.

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6. MEETINGS

6.1. Number of Meetings: The Subcommittee panel shall meet at least once, with additional meetings at the call of the Chair.

6.2. Notice of Meetings: Notice of a Subcommittee meeting should be provided to Subcommittee members, at least five (5) business days advance of the meeting, unless waived by the Subcommittee members at the meeting.

6.3. Agenda: Agenda items should be sent to the Subcommittee Administrative Support person no later than five

(5) Business Days prior to the date of the meeting. The agenda should be prepared and distributed to the members of the Subcommittee prior to the meeting.

6.4. Quorum: The presence of four (4) Subcommittee panel members shall constitute a quorum.

6.5. Decision-Making: The decision of the Subcommittee panel will be made by Subcommittee panel vote. The Chair of the Subcommittee will not vote except in the event of a tie.

6.6. Subcommittee Meeting Guests: All Subcommittee panel meetings will be limited to members only unless the Chair otherwise grants approval for certain individuals to attend all or a portion of the meeting.

6.7. Closed Sessions: Meetings shall be conducted as closed sessions, unless one party requests an open meeting and the other party, and the Chair agree with the request.

6.8. Electronic or Telephone Meetings and Email Discussion: The Chair may consult with Subcommittee panel members by email or arrange electronic or telephone meetings, instead of in-person meetings, as the circumstances may require.

6.9. Confidentiality: All Subcommittee members, resource persons, consultants, guests, and administrative support persons who may be in attendance at a Subcommittee panel meeting or privy to Subcommittee information, are required to protect and keep confidential any protected information (e.g., classified or privileged information) received through participation on the Subcommittee.

6.10. Minutes & Confidentiality: Minutes are to be taken of business occurring during Subcommittee meetings. However, the Subcommittee may move “in camera” to deal with certain items if the subject matter being considered relates to personal and confidential matters that are exempt from disclosure under applicable access and privacy legislation. Minutes taken during a panel meeting form part of the official record of the reconsideration.

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7. SUBCOMMITTEE ADMINISTRATIVE SUPPORT

7.1. The Subcommittee shall receive administrative support from the College. The administrative support shall be provided through an individual whose duties shall include:

a) Assisting the Chair with preparation of Subcommittee meeting agendas and distributing notification of meetings.

b) Ensuring follow-up of Subcommittee action items.

c) Information gathering.

d) Preparation and distribution of meeting material.

e) Minute-taking.

f) Maintaining Subcommittee records.

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8. AMENDMENTS TO TERMS OF REFERENCE

8.1. Amendments to these Terms of Reference may be proposed by the Subcommittee to the Admissions Committee of the College for approval.

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9. DATES OF APPROVAL, REVIEW AND REVISION

9.1. Date approved: Admissions Committee, Max Rady College of Medicine – November 29, 2023.

9.2. Review: Formal review of these terms will be conducted every five (5) years. In the interim these terms may be revised or rescinded as the Subcommittee may recommend or as the Committee otherwise deems necessary.

9.3. Supersedes: N/A

9.4. Subcommittee Contact: Admissions Administrator, Admissions Office

9.5. Effect on Previous Statements: These terms shall supersede all previous College terms on the subject matter herein.

1. PURPOSE AND MANDATE

1.1. Purpose/Mandate: The Canadian Indigenous Panel Selection Subcommittee (“Subcommittee”) is a subcommittee of the Admissions Committee (“Committee”), Max Rady College of Medicine (“College”), Rady Faculty of Health Sciences (“RFHS”), mandated by the Admissions Committee to recommend selection of successful applicants from the Canadian Indigenous Application Pool (“Indigenous Pool”) (its “Mandate”).

2. REPORTING AND ACCOUNTABILITY

2.1. Accountability: The Subcommittee is a subcommittee of, and reports to, the Committee.

2.2. Reporting: The Subcommittee, through the Chair, shall annually report to the Chair of the Committee.

3. CHAIRPERSON AND SUBCOMMITTEE MEMBERSHIP

3.1. Chair: The Chair of the Subcommittee shall be the Chair, Canadian Indigenous Panel of the Admissions Committee. The Chair is responsible for the following at Subcommittee meetings:

a) Calling the Subcommittee meeting(s) to order,

b) Establishing an agenda and ensuring agenda items are addressed,

c) If the meeting is a continuation of an ongoing selection deliberation, ensuring the minutes from prior meeting(s) are reviewed and approved by the Committee (with or without modification).

d) Facilitating discussion to reach consensus on matters under consideration in a professional manner, e) Adjourning meetings after business is concluded, and

f) Acting as the main representative of the Subcommittee.

3.2. Membership: The Subcommittee membership shall then consist of the following members, including the Chair:

(a) An Elder and/or Knowledge Keeper,

(b) One (1) Indigenous student representative selected by the Chair, (c) One (1) community member selected by the Chair,

(d) Two (2) members selected by the Chair for their previous experience as Panel interviewers, (e) The Admissions Advisor, Admissions, College (non-voting), and

(f) The Subcommittee Administrative Support (non-voting).

Chair of the Subcommittee in consultation with the Associate Dean, Admissions. All members must not have participated in the current application cycle as a Canadian Indigenous Panel interviewer.

3.3. Equitable, Inclusive and Diverse Membership: The College strives to achieve equitable, inclusive, and diverse membership on its committees that is reflective of its commitment to equity, diversity, and inclusion and this should be considered in the appointment of Subcommittee members.

3.4. Best Interests: Subcommittee members shall deal with matters before the Subcommittee in such a way that the best interests of the College take precedence over the interests of any of its constituent parts, should those interests conflict or appear to conflict.

3.5. Consultation: In carrying out its role, the Subcommittee may call upon various resources as it deems required.

4. TERM OF OFFICE

The term of office of each Subcommittee member shall be until the first of the following occurs: (a) the individual no longer holds the position noted in 3.2;

(b) the term of the appointment ends;

(c) the appointment is rescinded by the appointer; or

(d) the individual resigns from the Subcommittee.

5. FUNCTIONS AND ACTIVITIES OF SUBCOMMITTEE

5.1. As part of its Mandate, the Subcommittee will engage in the following activities at the meetings:

(a) Receive Information: The Subcommittee will receive, for review, all documents related to all applicants who applied through the Indigenous Pool. The review will focus on the established criteria for the Indigenous Pool.

(b) Request Information: The Subcommittee will request additional information, as required, from the Admissions Office.

(c) Decision-Making: The Subcommittee will deliberate and take a vote, in camera, regarding the recommendation of applicants for an offer through the Indigenous Pool.

(d) Reporting: The Subcommittee will present their decisions to the Committee.

6. MEETINGS

6.1. Number of Meetings: The Subcommittee shall meet at least once per year, and additional meetings at the call of the Chair.

6.2. Notice of Meetings: Notice of a Subcommittee meeting should be provided to Subcommittee members, at least ten (10) business days advance of the meeting, unless waived by the Subcommittee members at the meeting.

6.3. Agenda: Agenda items should be sent to the Subcommittee Administrative Support person at least 48 hours in advance of the meeting. The agenda should be prepared and distributed to the members of the Subcommittee prior to the meeting.

6.4. Quorum: A simple majority of the members of the Subcommittee shall constitute a quorum.

6.5. Decision-Making: The preferred model for decision-making is consensus. If consensus cannot be reached, the varying recommendations may be taken to a vote. The Chair of a Subcommittee will not vote except in the event of a tie.

6.6. Subcommittee Meeting Guests: All Subcommittee meetings will be limited to members only unless the Chair otherwise grants approval for certain individuals to attend all or a portion of the meeting.

6.7. Electronic or Telephone Meetings and Email Discussion: The Chair may consult with Subcommittee panel members by email or arrange electronic or telephone meetings, instead of in-person meetings, as the circumstances may require.

6.8. Confidentiality: All Subcommittee members, resource persons, consultants, guests, and administrative support persons who may attend a Subcommittee meeting or privy to Subcommittee information, are required to protect and keep confidential any protected information (e.g., classified or privileged information) received through participation on the Subcommittee. Confidential and protected information includes, but is not limited to, the personal information of all applicants, including their interview answers; the personal information of all individuals associated with the Indigenous Pool process, including their comments and opinions regarding the members, the applicants and the process; as well as all interview questions, rubrics, selection criteria, deliberations, and other procedural documentation that has been classified as confidential and privileged.

6.9. Minutes & Confidentiality: Minutes are to be taken of business occurring during Subcommittee meetings.

However, the Subcommittee may move “in camera” to deal with certain items if the subject matter being considered relates to personal and confidential matters that are exempt from disclosure under applicable access and privacy legislation. Minutes taken during a panel meeting form part of the official record of the reconsideration.

7. SUBCOMMITTEE ADMINISTRATIVE SUPPORT

The Subcommittee shall receive administrative support from the College. The administrative support shall be provided through an individual whose duties shall include:

a) Assisting the Chair with preparation of Subcommittee meeting agendas and distributing notification of meetings.

b) Ensuring follow-up of Subcommittee action items.

c) Information gathering.

d) Preparation and distribution of meeting material. e) Minute-taking; and

f) Maintaining Subcommittee records.

8. AMENDMENTS TO TERMS OF REFERENCE

Amendments to these Terms of Reference may be proposed by the Subcommittee to the Admissions Committee for approval.

9. DATES OF APPROVAL, REVIEW AND REVISION

9.1. Date approved: Admissions Committee – January 26, 2022

9.2. Review: Formal review of these terms will be conducted every five (5) years. In the interim these terms may be revised or rescinded as the Subcommittee may recommend or as the Committee otherwise deems necessary.3. Supersedes: N/A

9.4. Subcommittee Contact: Admissions Administrator, Admissions Office

9.5. Effect on Previous Statements: These terms shall supersede all previous College terms on the subject matter herein.

1. PURPOSE AND MANDATE

1.1 Purpose/Mandate: The General Admissions Appeal Subcommittee (“Subcommittee”) of the Admissions Committee (“Committee”), Max Rady College of Medicine (“College”), Rady Faculty of Health Sciences (“RFHS”) is established in accordance with the Reconsideration of Admissions Decisions (Admissions Appeals) Policy and the Max Rady College of Medicine Applicant Bulletin, to reconsider a decision of the Admissions Committee of the College excluding appeals relating to those who manifest professionalism concerns or appeals relating to the Canadian Indigenous Panel Interview (“Panel Interview”).

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2. REPORTING AND ACCOUNTABILITY

2.1. Accountability: The Subcommittee is established on an ad hoc basis at the call of the Chair of the Committee, to reconsider admissions decision in accordance with this Terms of Reference and the Reconsideration of Admissions Decision Policy of the College.

2.2. Reporting: The Subcommittee, through the Chair, shall annually report to the Chair of the Committee, respecting the number, types of requests for reconsideration, and the outcomes determined by the Subcommittee, without comprising the confidentiality of the process.

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3. CHAIRPERSON AND SUBCOMMITTEE MEMBERSHIP

3.1. Chair: The Chair of the Subcommittee shall be appointed by the Chair, Admissions Committee. The Chair is responsible for the following at Review Panel meetings:

(a) Receiving and reviewing an applicant’s request for reconsideration, to determine whether it has jurisdiction, and whether there are grounds for reconsideration.

(b) Communicating with the applicant and Chair, Admissions Committee, respecting requests for reconsideration and any determinations.

(c) Calling the Subcommittee meeting(s) to order.

(d) Establishing an agenda and ensuring agenda items are addressed.

(e) If the meeting is a continuation of an ongoing reconsideration of decision hearing, ensuring the minutes from prior meeting(s) are reviewed and approved by the Committee (with or without modification).

(f) Facilitating discussion to reach consensus on matters under consideration in a professional manner.

(g) Adjourning meetings after business is concluded.

(h) Acting as the main representative of the Subcommittee. 

3.2. Subcommittee Membership: A panel of the Subcommittee will be constituted on an ad hoc basis, to reconsider admission decisions as required. The panel shall then consist of the following members, including the Chair:

(a) College Representative: One faculty member of the Max Rady College of Medicine.

(b) Indigenous Faculty Representative: One Indigenous faculty member of the Rady Faculty of Health Sciences.

(c) Student Representative: One Med student representative.

(d) MMI Representative: One individual with experience as an interviewer or rater for the Multiple-Mini Interview.

All representatives appointed by the Chair, Admissions Committee.

3.3. Equitable, Inclusive and Diverse Membership: The College strives to achieve equitable, inclusive, and diverse membership on its committees that is reflective of its commitment to equity, diversity, and inclusion and this should be considered in the appointment of Subcommittee panel members.

3.4. Best Interests: Subcommittee panel members shall deal with matters before the Subcommittee in such a way that the best interests of the College take precedence over the interests of any of its constituent parts, should those interests conflict or appear to conflict.

3.5. Consultation: In carrying out its role, the Subcommittee may call upon various resources as it deems required.

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4. TERM OF OFFICE

4.1. The term of office of each Subcommittee panel member shall be for the duration of hearing and determining a reconsideration decision. The panel will be disbanded once a determination has been made.

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5. FUNCTIONS AND ACTIVITIES OF SUBCOMMITTEE

5.1. As part of its Mandate, the Subcommittee will engage in the following activities:

a. Receive Information: The Subcommittee will receive, for review, all documents related to the applicant’s request for reconsideration.

b. Determine Jurisdiction and Grounds: The Subcommittee will determine if the appeal meets the established jurisdiction of the Subcommittee and whether there are grounds for reconsideration.

c. Request Information: The Subcommittee will request additional information, as required, from the Admissions Office.

d. Meet with the Applicant: The Subcommittee will meet with the applicant to hear their oral submissions, along with a student advocate or other support person, if desired, as well as any other individuals deemed necessary. 

e. Decision-Making: The Subcommittee will deliberate and take a vote, in camera, regarding the request for reconsideration.

f. Reporting: The Subcommittee will present their decisions to the Committee.

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6. MEETINGS

6.1. Number of Meetings: The Subcommittee panel shall meet at least once, with additional meetings at the call of the Chair.

6.2. Notice of Meetings: Notice of a Subcommittee meeting should be provided to Subcommittee members, at least five (5) business days advance of the meeting, unless waived by the Subcommittee members at the meeting.

6.3. Agenda: Agenda items should be sent to the Subcommittee Administrative Support person no later than five

(5) Business Days prior to the date of the meeting. The agenda should be prepared and distributed to the members of the Subcommittee prior to the meeting.

6.4. Quorum: The presence of four (4) Subcommittee panel members shall constitute a quorum.

6.5. Decision-Making: The decision of the Subcommittee panel will be made by Subcommittee panel vote. The Chair of a Subcommittee will not vote except in the event of a tie.

6.6. Subcommittee Meeting Guests: All Subcommittee panel meetings will be limited to members only unless the Chair otherwise grants approval for certain individuals to attend all or a portion of the meeting.

6.7. Closed Sessions: Meetings shall be conducted as closed sessions, unless one party requests an open meeting and the other party, and the Chair agree with the request.

6.8. Electronic or Telephone Meetings and Email Discussion: The Chair may consult with Subcommittee panel members by email or arrange electronic or telephone meetings, instead of in-person meetings, as the circumstances may require.

6.9. Confidentiality: All Subcommittee members, resource persons, consultants, guests, and administrative support persons who may be in attendance at a Subcommittee panel meeting or privy to Subcommittee information, are required to protect and keep confidential any protected information (e.g., classified or privileged information) received through participation on the Subcommittee.

6.10. Minutes & Confidentiality: Minutes are to be taken of business occurring during Subcommittee meetings. However, the Subcommittee may move “in camera” to deal with certain items if the subject matter being considered relates to personal and confidential matters that are exempt from disclosure under applicable access and privacy legislation. Minutes taken during a panel meeting form part of the official record of the reconsideration.

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7. SUBCOMMITTEE ADMINISTRATIVE SUPPORT

7.1. The Subcommittee shall receive administrative support from the College. The administrative support shall be provided through an individual whose duties shall include:

a) Assisting the Chair with preparation of Subcommittee meeting agendas and distributing notification of meetings.

b) Ensuring follow-up of Subcommittee action items.

c) Information gathering.

d) Preparation and distribution of meeting material.

e) Minute-taking.

f) Maintaining Subcommittee records.

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8. AMENDMENTS TO TERMS OF REFERENCE

8.1. Amendments to these Terms of Reference may be proposed by the Subcommittee to the Admissions Committee of the College for approval.

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9. DATES OF APPROVAL, REVIEW AND REVISION

9.1. Date approved: Admissions Committee, Max Rady College of Medicine – November 29, 2023

9.2. Review: Formal review of these terms will be conducted every five (5) years. In the interim these terms may be revised or rescinded as the Subcommittee may recommend or as the Committee otherwise deems necessary.

9.3. Supersedes: N/A

9.4. Subcommittee Contact: Admissions Administrator, Admissions Office

9.5. Effect on Previous Statements: These terms shall supersede all previous College terms on the subject matter herein.

1. PURPOSE AND MANDATE

Purpose/Mandate: The MMI Question Selection Subcommittee (“Subcommittee”) is a subcommittee of the Admissions Committee (“Admissions Committee”), Max Rady College of Medicine (“College”), Rady Faculty of Health Sciences (“RFHS”), mandated by the Admissions Committee to develop and implement MMI stations for the purpose of the Admissions Committee’s mandatory, on-site admissions interviews (its “Mandate”).

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2. REPORTING AND ACCOUNTABILITY

2.1. Accountability: The Subcommittee is a subcommittee of, and reports to, the Admissions Committee.

2.2. Reporting: The Subcommittee, through the Chair, shall report to the Chair of the Admissions Committee.

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3. CHAIRPERSON AND SUBCOMMITTEE MEMBERSHIP

3.1. Chair: The Chair of the Subcommittee shall be the Associate Dean, Admissions, of the College. The Chair is responsible for the following at Subcommittee meetings:

a) Calling the meeting to order;

b) Establishing an agenda and ensuring agenda items are addressed;

c) Facilitating discussion to reach consensus on matters under consideration in a professional manner;

d) Adjourning meetings after business is concluded; and

e) Acting as the main representative of the Subcommittee.

3.2. Membership: The Subcommittee membership shall then consist of the following members, including the Chair:

(a) One student representative appointed by the Manitoba Medical Student Association; (b) Director, Equity, Diversity and Inclusion, RFHS;

(c) Anti-Racism Practice Lead, RFHS;

(d) One representative from Ongomiizwin, appointed by the Executive Director, Indigenous Academic Affairs, Ongomiizwin;

(e) Three members selected by the Chair for their previous experience as MMI interviewers.

(f) The Administrator, Admissions, College (non-voting);

(g) The Admissions Advisor, Admissions, College (non-voting);

(h) The Subcommittee Administrative Support (non-voting).

Designates/alternates will not be allowed. The number of members for the Subcommittee may fluctuate to accommodate changes in the format of the MMI and number of questions required each year. Additional representation may be added at the discretion of the Chair of the Subcommittee in consultation with the Administrator, Admissions.

information, are required to protect and keep confidential any protected information (e.g., classified or privileged information) received through participation on the Subcommittee.

6.8. Minutes: Minutes are to be taken of business occurring during Subcommittee meetings. Once approved by the

Subcommittee, meeting minutes shall be publicly available, in accordance with applicable legislation.

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7. SUBCOMMITTEE ADMINISTRATIVE SUPPORT

The Subcommittee shall receive administrative support from the College. The administrative support shall be provided through an individual whose duties shall include:

a) Assisting the Chair with preparation of Subcommittee meeting agendas and distributing notification of meetings;

b) Ensuring follow-up of Subcommittee action items;

c) Information gathering;

d) Preparation and distribution of meeting material;

e) Minute-taking; and

f) Maintaining Subcommittee records.

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8. AMENDMENTS TO TERMS OF REFERENCE

Amendments to these Terms of Reference may be proposed by the Subcommittee to the Admissions Committee for approval.

9. DATES OF APPROVAL, REVIEW AND REVISION

9.1. Date approved: Admissions Committee – October 21, 2020

9.2. Review: Formal review of these terms will be conducted every five (5) years. In the interim these terms may be revised or rescinded if the Subcommittee deems necessary.

9.3. Supersedes: N/A

9.4. Subcommittee Contact: Administrator, Admissions

9.5. Effect on Previous Statements: These terms shall supersede all previous College terms on the subject matter herein.

Policy name	Professionalism in admissions policy
Application and scope	Applicants to the Doctor of Medicine (MD) program in the Max Rady College of Medicine who manifest professionalism concerns.
Approved date	March 8, 2022
Review date	Five (5) years from the approval date
Revised date	May 2, 2023
Approved by	College Council, Max Rady College of Medicine

1. PURPOSE

To set out the jurisdiction, grounds and process respecting the review of Applicants who manifest concerns that may be predictive of future breaches of professionalism by the Professionalism Subcommittee on Admissions, a subcommittee of the Admissions Committee of the Max Rady College of Medicine, in accordance with the Professionalism Subcommittee on Admissions Terms of Reference and the Review Panel Terms of Reference.

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2. DEFINITIONS

2.1 Applicant – includes individuals who have applied for admission to Undergraduate Medical Education Program, leading to the Doctor of Medicine degree in the Max Rady College of Medicine.

2.2 Applicant Information Bulletin (Bulletin) – the official policy document for an application to the Undergraduate Medical Education Program in the Max Rady College of Medicine, leading to the Doctor of Medicine degree. The Bulletin outlines the Senate approved categories of admission, requirements, and deadlines, and is constitutes a part of the application. It is assumed that all applicants have read and understood the contents of the Bulletin prior to submitting their completed application.

2.3 Business Day – Any day, other than a Saturday, Sunday, or legal holiday on which academic business may be conducted. Max Rady College of Medicine usual workday hours are Monday through Friday 8:00 a.m. to 4:00 p.m.

2.4 Canadian Indigenous Applicant Pool (Indigenous Pool) – the applicant pool designated for applicants who are either Canadian citizens or Permanent Residents and have declared their First Nations, Metis, or Inuit heritage. All applicants to the Indigenous Pool who meet the eligibility requirements set out in the Bulletin will be offered an interview. Offers of admission will be extended to applicants who are recommended to the Admissions Committee by the Canadian Indigenous Applicant Pool panel, regardless of composite score.
 
2.5 Canadian Medical Association (CMA) – a national organization for medical professionals.

2.6 External Complainant – these are individuals from outside the University of Manitoba, such as the general public, who have contacted the Admissions Office with concerns regarding the conduct of an Applicant and/or the Applicant’s suitability for the medical profession.

2.7 Internal Complainant – these are individuals from within the University of Manitoba community, such as staff, faculty, or students, who have contacted the Admissions Office with concerns regarding the conduct of an Applicant and/or the Applicant’s suitability for the medical profession.

2.8 Multiple-Mini Interview (MMI) – the interview format used to assess non-academic attributes of all Applicants.

2.9 MMI Rater or Interviewer – the individuals involved in the MMI who either interview or rate an Applicant’s response to a scenario or question used in the MMI. The MMI Rater or Interviewer will then score the Applicant on a Score Card based on a rubric.

2.10 Panel Interview – the interview format used to assess non-academic attributes of Applicants from the Canadian Indigenous Applicant Pool.

2.11 Panel Interviewer – the individuals who conduct interviews with Applicants from the Indigenous Pool and complete a score card regarding the Applicants’ performance in the interview.

2.12 Professionalism – as defined by the Canadian Medical Association (CMA) Code of Ethics and Professionalism.

2.13 Professionalism Subcommittee on Admissions (PSA) – the Subcommittee responsible to review the applications of individuals who have applied to the Undergraduate Medical Education Program and who manifest concerns that may be predictive of future breaches of professionalism.

2.14 Red Flag – a concern brought forward by a third party regarding the applicant’s behaviour and/or suitability for the medical profession. A Red Flag may include, but not be limited to, comments from interviewers, referees, University staff members, and/or community members external to the University. Disclosures sent in by the applicant regarding criminal records would also be considered a Red Flag.

2.15 Referee – an individual selected by the Applicant to complete a Reference Letter regarding the Applicant’s professional attributes and suitability for the medical profession. Applicants who are invited to interview must submit the names of three (3) Referees to complete the Reference Letter.

2.16 Reference Letter – a form created by the Admissions Committee that all Referees must fill out regarding the Applicant who nominated them as a Referee. The form assesses the Applicant’s professional attributes and suitability for the medical profession.

2.17 Station Lead – the individual assigned to train the MMI Raters or Interviewers based on their level of expertise as it relates to the MMI station’s content.
 
2.18 Undergraduate Medical Education (UGME) Program – the four-year Doctor of Medicine (MD) degree program within the Max Rady College of Medicine.

2.19 UGME Admissions Office – the undergraduate medical education office that oversees the implementation of published policies and processes in relation to the admissions process in the Max Rady College of Medicine, leading to the Doctor of Medicine degree.

2.20 Undergraduate Admissions Office, Enrolment Services – the central undergraduate admissions office that oversees the implementation of published policies and processes in relation to the admissions process of all undergraduate degrees at the University of Manitoba.

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4. REFERENCES

4.1 Terms of Reference: Admissions Committee, Max Rady College of Medicine

4.2 Terms of Reference: Professionalism Subcommittee on Admissions, Max Rady College of Medicine

4.3 Applicant Information Bulletin, Max Rady College of Medicine

4.4 Disruption of all Forms of Racism Policy, Rady Faculty of Health Sciences

4.5 The Human Rights Code, Province of Manitoba

4.6 Code of Ethics and Professionalism, Canadian Medical Association

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5. POLICY CONTACT

Please contact the associate dean, admissions, with questions respecting this policy.

1. PURPOSE AND MANDATE

1.1. Purpose/Mandate: The Professionalism Subcommittee on Admissions (“Committee”) is a subcommittee of the Admissions Committee of the Max Rady College of Medicine (“College”), established to review the applications/information of individuals who have applied to the Undergraduate Medical Education (“UGME”) Program and who manifest concerns that may be predictive of future breaches of professionalism. Such concerns include but are not limited to a criminal conviction; inclusion in a child abuse registry; a record of academic discipline; a significantly negative letter of reference; a breach of academic integrity; concerns

identified in the application process; concerns identified in the Multiple Mini Interview (“MMI”) (its “Mandate”).

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2. REPORTING AND ACCOUNTABILITY

2.1. Accountability: The Committee is a subcommittee of the Admissions Committee.

2.2. Reporting: The Committee, through the Chair, shall report a summary of its conclusions and recommendations to the Chair, Admissions Committee. The final decision to grant an interview, offer admission, or refuse to offer admission, to an applicant, is the responsibility of the Admissions Committee.

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3. CHAIRPERSON AND COMMITTEE MEMBERSHIP

3.1. Chair: The Chair of the Committee shall be the Associate Dean, Professionalism of the College. The Chair is responsible for the following at Committee meetings:

(a) Calling the meeting to order,

(b) Establishing an agenda and ensuring agenda items are addressed,

(c) Ensuring the minutes from prior meeting(s) are reviewed and approved by the Committee (with or without modification),

(d) Facilitating discussion to reach consensus on matters under consideration in a professional manner, (e) Adjourning meetings after business is concluded, and

(f) Acting as the main representative of the Committee.

3.2. Membership: The Committee membership shall then consist of the following members, including the Chair: (a) The Vice-Dean, Indigenous,

(b) The Associate Dean, PGME, College,

(c) Information gathering,

(d) Preparation and distribution of meeting material, (e) Minute-taking, and

(f) Maintaining Committee records.

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8. AMENDMENTS TO TERMS OF REFERENCE

8.1. Amendments to these Terms of Reference may be proposed by the Committee to the Admissions Committee for approval.

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9. DATES OF APPROVAL, REVIEW AND REVISION

9.1. Date approved: Admissions Committee – January 26, 2022

9.2. Review: Formal review of these terms will be conducted every five (5) years. In the interim these terms may be revised or rescinded if the Admissions Committee deems necessary.

9.3. Supersedes: Professionalism Subcommittee on Admissions – Terms of Reference (October 21, 2020, May 11, 2021)

9.4. Committee Administrative Support: Assistant to the Associate Dean, Professionalism

9.5. Effect on Previous Statements: These terms shall supersede all previous College terms on the subject matter herein.

Policy name	Reconsideration of admissions decisions (admissions appeals policy)
Application and scope	Applicants wishing reconsideration of a decision of the Admissions Committee, Max Rady College of Medicine
Approved date	December 21, 2021
Review date	Five (5) years from the approval date
Revised date
Approved by	College Executive Council, Max Rady College of Medicine

1. PURPOSE

To set out the jurisdiction, grounds and process respecting initial reconsideration of a decision of the Admissions Committee, Max Rady College of Medicine, in accordance with the University of Manitoba Senate Committee on Admission Appeals Policy and Procedure.

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2. DEFINITIONS

2.1 Admissions Appeal Subcommittees – the three Subcommittees of the Admissions Committee, Max Rady College of Medicine, which reconsider a decision of the Admissions Committee. The three Subcommittees each have different jurisdiction and work independently of each other. The Subcommittees are the Canadian Indigenous Panel Appeal Subcommittee, the General Admissions Appeal Subcommittee, and the Professionalism in Admissions Appeal Subcommittee.

2.2 Applicant – includes individuals who have applied for admission to the undergraduate medical education (UGME) program, leading to the Doctor of Medicine (MD) degree in the Max Rady College of Medicine.

2.3 Applicant Information Bulletin (“Bulletin”) – the official policy document for an application to the UGME program in the Max Rady College of Medicine, leading to an MD degree. The Bulletin outlines the Senate approved categories of admission, requirements, and deadlines, and is constitutes a part of the application. It is assumed that all applicants have read and understood the contents of the Bulletin prior to submitting their completed application.

2.4 Business Day – Any day, other than a Saturday, Sunday, or legal holiday on which academic business may be conducted. Max Rady College of Medicine usual workday hours are Monday through Friday 8:00 a.m. to 4:00 p.m.

2.5 Canadian Indigenous Panel Appeal Subcommittee – the Subcommittee responsible to reconsider a decision of the Admissions Committee, Max Rady College of Medicine, regarding an applicant from the Canadian Indigenous Applicant Pool in accordance with this policy and its terms of reference.

2.6 Canadian Indigenous Applicant Pool (“Indigenous Pool”) – the applicant pool designated for applicants who are either Canadian citizens or Permanent Residents and have declared their First Nations, Metis, or Inuit heritage. All applicants to the Indigenous Pool who meet the Adjusted Grade Point Average (AGPA) eligibility requirements set out in the Bulletin will be offered an interview. Offers of admission will be extended to applicants who are recommended to the Admissions Committee by the Canadian Indigenous Applicant Pool panel, regardless of composite score.

2.7 General Admissions Appeal Subcommittee – the Subcommittee responsible to reconsider a decision of the Admissions Committee, Max Rady College of Medicine, regarding an applicant from the Manitoba Applicant Pool or the Out-of-Province Applicant Pool except in the case where the appeal is regarding a professionalism concern or a concern regarding the Canadian Indigenous Panel Interview. The Subcommittee will also reconsider a deferral decision or transfer policy decision for applicants of any of the applicant pools or streams.

2.8 Manitoba Applicant Pool (“MB Pool”) – the applicant pool designated for applicants who are either Canadian citizens or Permanent Residents and meet the definition of a Manitoba resident as outlined in the Bulletin. Applicants in this pool are ranked within their respective pool and only those whose composite score is deemed to be competitive within their pool will be invited for an interview or extended an offer of admission. The Admissions Committee gives priority to Manitoba applicants.

2.9 Out-of-Province Applicant Pool (“OOP Pool”) – the applicant pool designated for applicants who are either Canadian citizens or Permanent Residents and do not meet the definition of a Manitoba resident as outlined in the Bulletin. Applicants in this pool are ranked within their respective pool and only those whose composite score is deemed to be competitive within their pool will be invited for an interview or extended an offer of admission. The Admissions Committee reserves up to 5% of spots for Out-of-Province applicants.

2.10 Professionalism in Admissions Appeal Subcommittee – the Subcommittee responsible to reconsider a decision of the Admissions Committee, Max Rady College of Medicine, regarding an applicant who manifests professionalism concerns in accordance with this policy and its terms of reference.

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3. POLICY & PROCEDURE STATEMENTS

3.1 Formal Admissions Appeal Process

Applicants who desire a reconsideration of a decision of the Admissions Committee shall submit, in writing, a formal request for reconsideration and include all supporting documentation within ten (10) Business Days of the electronic notification of the decision the applicant wishes to have reviewed. It shall be sent to the Chair, Admissions Committee at:

Chair, Admissions Committee
Max Rady College of Medicine
260 Brodie Centre, 727 McDermot Avenue
Winnipeg, MB R3E 3P5
Medicine.Admissions@umanitoba.ca

3.2 Assignment of Appeal to Appropriate Admissions Appeal Subcommittee

The Chair, Admissions Committee, will review the formal requests for reconsideration to determine which appeal subcommittee will have jurisdiction.

3.3 Jurisdiction and Grounds for Reconsideration by the Professionalism in Admissions Appeal Subcommittee

The Professionalism in Admissions Appeal Subcommittee has jurisdiction to reconsider a decision of the Admissions Committee including without limitation a decision respecting an Applicant’s admission to the UGME program or rescission of an Applicant’s offer to the UGME program. The grounds for reconsideration are:

• The matter relates directly to a decision respecting the Applicant’s own admission to the UGME program.
• The Applicant believes that published and applicable Professionalism in Admissions policies or procedures have not been applied fairly, or that procedural errors in the application of the policies/procedures has occurred.

3.4 Jurisdiction and Grounds for Reconsideration by the Canadian Indigenous Panel Appeal Subcommittee

The Canadian Indigenous Panel Appeal Subcommittee has jurisdiction to reconsider a decision of the Admissions Committee including without limitation a decision respecting an Applicant’s admission to the UGME program or rescission of an Applicant’s offer to the UGME program. The grounds for reconsideration are:

• The matter relates directly to a decision respecting the Applicant’s own admission to the UGME program.
• The Applicant applied through the Indigenous Pool.
• The Applicant believes that published applicable Canadian Indigenous Applicant

Pool policies or procedures have not been applied fairly or that procedural errors in the application of the policies/procedures has occurred.

3.5 Jurisdiction and Grounds for Reconsideration by the General Admissions Appeal Subcommittee

The General Admissions Appeal Subcommittee has jurisdiction to reconsider a decision of the Admissions Committee including without limitation a decision respecting an Applicant’s admission to the UGME program or rescission of an Applicant’s offer to the UGME program. The grounds for reconsideration are:

• The matter relates directly to a decision respecting the Applicant’s own admission to the UGME program.
• The matter relates directly to a decision involving the MMI, a deferral request, a transfer request, and/or policies or procedures relating to the MB Pool or the OOP Pool.
• The matter is not associated with a professionalism concern nor the Canadian

• Indigenous Panel process.
• The Applicant believes that published and applicable policies or procedures have not been applied fairly or that procedural errors in the application of the policies/procedures has occurred.

3.6 The Chair of the Admissions Appeal Subcommittee selected by the Chair, Admissions Committee based on the above criteria will review the Applicant’s request for reconsideration and determine whether it has jurisdiction and there are grounds for reconsideration.

3.7 The Chair of the selected Admissions Appeal Subcommittee may transfer an appeal to a different Admissions Appeal Subcommittee as necessary and appropriate to meet the jurisdiction requirements.

3.8 The Chair of the appropriate Admissions Appeal Subcommittee having jurisdiction shall send a letter to the Applicant and the Chair, Admissions Committee, notifying the parties of its determination to either not consider the matter, or that a meeting will occur to reconsider the decision. The Applicant may appeal to the University of Manitoba Senate Committee on Admission Appeals if the Chair of the appropriate Admissions Appeal Subcommittee decides the reconsideration will not be considered.

3.9 If the Chair of the appropriate Admissions Appeal Subcommittee determines there is jurisdiction and grounds to consider the matter, the Chair of said Subcommittee will convene a panel of that Admissions Appeal Subcommittee to meet to reconsider the decision.

3.10 In its letter to the Applicant and Chair, Admissions Committee, the Chair of the appropriate Admissions Appeal Subcommittee must notify the parties of the names of all individuals participating in the meeting including the names of the Subcommittee members. This is to ensure that no conflict of interest between the Applicant, Admissions Committee, and Admissions Appeal Subcommittee will occur. In the case of a potential conflict of interest, either party can voice an objection to the Chair of the appropriate Admissions Appeal Subcommittee, who will review the objection and decide if there is a need to reformat the membership of the appropriate Admissions Appeal Subcommittee. The decision of the Chair of the appropriate Admissions Appeal Subcommittee will be binding on both parties.

3.11 The Chair, Admissions Committee, must respond to the Chair of the appropriate Admissions Appeal Subcommittee within five (5) Business Days of the date of notification of the meeting, providing all supporting documentation it believes relevant to the decision.

3.12 The Chair of the appropriate Admissions Appeal Subcommittee shall submit a copy of the supporting documents received by the Chair, Admissions Committee to the Applicant within five (5) Business Days of receipt of the documentation, and no later than five (5) Business Days prior to the date of the meeting.

3.13 A meeting should take place within fifteen (15) Business Days of the date of receipt, by the Chair of the appropriate Admissions Appeal Subcommittee of the formal request for reconsideration.

3.14 The panel of the appropriate Admissions Appeal Subcommittee shall have the option to invite the Applicant and the Chair, Admissions Committee, to appear at the meeting for reconsideration. The Applicant may have one support person and/or one legal counsel present during the meeting. Neither of these parties may present at the meeting. If the Applicant or Chair, Admissions Committee chooses not to attend the meeting, the meeting will continue in absentia.

3.15 If the Admissions Appeal Subcommittee members require more information to make a decision, the Chair may schedule an additional meeting to allow for this information to be provided.

3.16 The decision of the Admissions Appeal Subcommittees will be made by committee vote.

The Chair of the Admissions Appeal Subcommittee hearing a matter shall not vote except in the case of a tie.

3.17 The decision will be communicated to the Applicant and the Chair, Admissions Committee, in writing, within ten (10) Business Days of the meeting.

3.18 The Chair of the appropriate Admissions Appeal Subcommittee shall advise the Applicant that they have a right to appeal the Subcommittee’s decision to the Senate Committee on Admission Appeals, subject to the Senate Committee on Admission Appeals Policy and Procedure.

3.19 All presentations, discussion and deliberations of the meeting will be kept confidential.

3.20 All submitted paper documentation for both parties will be returned to the office of the Associate Dean, Admissions, after the meeting. Electronic documentation must be deleted from all devices and applications used to access the documentation.

3.21 The Chair of each Admissions Appeal Subcommittee will report annually to the Chair, Admissions Committee of the Max Rady College of Medicine, concerning the number, types of requests for reconsideration, and outcomes determined by the Admissions Appeal Subcommittee, without compromising the confidentiality of the process.

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4. REFERENCES

4.1 The University of Manitoba Senate Committee on Admission Appeals Policy and Procedure

4.2 Terms of Reference: General Admissions Appeal Subcommittee Max Rady College of Medicine

4.3 Terms of Reference: Canadian Indigenous Panel Appeal Subcommittee Max Rady College of Medicine

4.4 Terms of Reference: Professionalism in Admissions Appeal Subcommittee, Max Rady College of Medicine

4.5 Terms of Reference: Professionalism Subcommittee on Admissions, Max Rady College of Medicine

4.6 The Max Rady College of Medicine Professionalism in Admissions Policy

4.7 Applicant Information Bulletin, Max Rady College of Medicine

4.8 Terms of Reference: Admissions Committee, Max Rady College of Medicine

4.9 The Max Rady College of Medicine Transfer Policy

4.10 Terms of Reference: Transfer Subcommittee, Max Rady College of Medicine

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5. POLICY CONTACT

Please contact Associate Dean, Admissions, with questions respecting this policy.

1. PURPOSE AND MANDATE

Purpose/Mandate: The Transfer Subcommittee (“Subcommittee”) is a subcommittee of the Admissions Committee (“Admissions Committee”), Max Rady College of Medicine (“College”), Rady Faculty of Health Sciences (“RFHS”), mandated by the Admissions Committee to review and determine eligibility for any transfer applicants to the undergraduate medical education (“UGME”) program (its “Mandate”).

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2. REPORTING AND ACCOUNTABILITY

2.1. Accountability: The Subcommittee is a subcommittee of, and reports to, the Admissions Committee.

2.2. Reporting: The Subcommittee, through the Chair, shall report to the Chair of the Admissions Committee.

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3. CHAIRPERSON AND SUBCOMMITTEE MEMBERSHIP

3.1. Chair: The Chair of the Subcommittee shall be the Associate Dean, Admissions, of the College. The Chair is responsible for the following at Subcommittee meetings:

a) Calling the meeting to order;

b) Establishing an agenda and ensuring agenda items are addressed;

c) Facilitating discussion to reach consensus on matters under consideration in a professional manner;

d) Adjourning meetings after business is concluded; and

e) Acting as the main representative of the Subcommittee.

3.2. Membership: The Subcommittee membership shall then consist of the following members, including theChair:

(a) The Associate Dean, UGME, College;

(b) The student representative that sits on the Admissions Committee; (c) Two faculty members of the Admissions Committee, College;

(d) The Administrator, Admissions, College (non-voting);

(e) The Admissions Advisor, Admissions, College (non-voting); (f) The Subcommittee Administrative Support (non-voting).

3.3. Equitable, Inclusive and Diverse Membership: The College strives to achieve equitable, inclusive and diverse membership on its committees that is reflective of its commitment to equity, diversity and inclusion and this should be considered in the appointment of Subcommittee members.

3.4. Best Interests: Subcommittee members shall deal with matters before the Subcommittee in such a way that the best interests of the College take precedence over the interests of any of its constituent parts, should those interests conflict or appear to conflict.

3.5. Consultation: In carrying out its role, the Subcommittee may call upon various resources as it deems required.

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4. TERM OF OFFICE

The term of office of each Subcommittee member shall be until the first of the following occurs: (a) the individual no longer holds the position noted in 3.2;

(b) the term of the appointment ends;

(c) the appointment is rescinded by the appointer; or

(d) the individual resigns from the Subcommittee.

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5. FUNCTIONS AND ACTIVITIES OF SUBCOMMITTEE

5.1. As part of its Mandate, the Subcommittee will engage in the following activities at the meetings:

(a) Review the transfer application package to ensure all required elements are provided, in accordance with the Transfer into the Undergraduate Medical Education Program Polic yof the College;

(b) Review the transfer applications to determine eligibility for transfer, applying the criteria in the Transfer into the Undergraduate Medical Education Program Policy of the College;

(c) Interview eligible transfer applicants;

(d) Notify transfer applicants respecting their eligibility to transfer and advise that eligible transfer applicants’ admissions are contingent on there being an open position for transfer.

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6. MEETINGS

6.1. Number of Meetings: The Subcommittee shall meet, as needed, to review transfer applications, at the call of the Chair.

6.2. Notice of Meetings: Notice of a Subcommittee meeting should be provided to Subcommittee members, at least two (2) weeks in advance of the meeting.

6.3. Agenda: The agenda, with the files for review, should be prepared and distributed to the members of the Subcommittee at least one (1) week prior to the meeting.

6.4. Quorum: A simple majority of the members of the Subcommittee shall constitute a quorum.

6.5. Decision-Making: The preferred model for decision-making is consensus. If consensus cannot be reached, the varying recommendations may be taken to a vote. The Chair shall only vote in the case of a tie.

6.6. Subcommittee Meeting Guests: All Subcommittee meetings will be limited to members only unless the Chair otherwise grants approval for certain individuals to attend all or a portion of the meeting.

6.7. Confidentiality: All meetings, deliberations, and materials for review are confidential. All Subcommittee members, resource persons, consultants, guests, and administrative support persons who may be in attendance at a Subcommittee meeting or privy to Subcommittee information, are required to protect and keep confidential any protected information (e.g., classified or privileged information) received through participation on the Subcommittee.

6.8. Minutes & Confidentiality: Minutes are to be taken of business occurring during Subcommittee meetings.

However, the Subcommittee shall move “in camera” to deal with certain items if the subject matter being considered relates to personal and confidential matters that are exempt from disclosure under applicable access and privacy legislation.

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7. SUBCOMMITTEE ADMINISTRATIVE SUPPORT

The Subcommittee shall receive administrative support from the College. The administrative support shall be provided through an individual whose duties shall include:

a) Assisting the Chair with preparation of Subcommittee meeting agendas and distributing notification of meetings;

b) Ensuring follow-up of Subcommittee action items;

c) Information gathering;

d) Preparation and distribution of meeting material;

e) Minute-taking; and

f) Maintaining Subcommittee records.

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8. AMENDMENTS TO TERMS OF REFERENCE

Amendments to these Terms of Reference may be proposed by the Subcommittee to the Admissions Committee for approval.

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9. DATES OF APPROVAL, REVIEW AND REVISION

9.1. Date approved: Admissions Committee – October 21, 2020

9.2. Review: Formal review of these terms will be conducted every five (5) years. In the interim these terms may be revised or rescinded if the Subcommittee deems necessary.

9.3. Supersedes: N/A

9.4. Subcommittee Contact: Administrator, Admissions

9.5. Effect on Previous Statements: These terms shall supersede all previous College terms on the subject matter herein.

Policy name	Undergraduate Medical Education (UGME) student appeals
Application and scope	All UGME Students
Approved date	August 2018
Review date	August 2023
Revised date	August 2018
Approved by	Curriculum Executive Committee (August 2018) College Executive Council (August 2018)

1. PURPOSE

4.1 The student must appeal within 10 working days to the UGME S.A.C. after receipt of a UGME committee decision.

4.40 If the committee members require more information to make a decision, the Chair may schedule an additional meeting to allow for this.

4.41 When the decision has been made, the Chair will communicate the decision to the student and respondent in writing within 2 working days of the appeal decision.

4.42 The Chair shall advise the student that he/she has a right to appeal the UGME S.A.C. decision to the Max Rady College of Medicine S.A.C. if the student is not accepting of the decision.

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5. POLICY CONTACT

Please contact Associate Dean, UGME with questions respecting this policy.

These program-specific materials can be found on Entrada:

• Appeals
• Examinations
• Forms

Access Entrada

Policy name	Resident appeals
Application and scope	All postgraduate medical education residents
Approved date	CPGME Executive: May 14, 2019; Dean’s Council: August 27, 2019
Review date	Five (5) years from the approved date
Revised date	November 2018
Approved by	College Executive Council, Sept. 17, 2019

Background

There are several levels at which postgraduate trainees have the opportunity to appeal assessment decisions which might have a major impact on their progression and promotion in their Residency Program, particularly those involving Remediation, Probation and Dismissal. The levels of academic appeal include the following:

Competency-Based Medical Education – is an outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies

Summative Assessment – is a process of assessment that is based on multiple sources of feedback on the global performance of the trainee over a specified period of time or over a stage of training

2.4 With respect to appeals of Probation decisions, the trainee may appeal only the outcome decision at the conclusion of the Probation

2.8.3 Max Rady College of Medicine Academic Appeals Committee hears appeals pursued by residents as follows:

3.1.3.9 The Chair is responsible for writing a decision letter including a summary of reasons for the RPC or Ad Hoc Departmental Appeal Committee decision

3.1.3.9.1 The decision letter will be sent within twenty working days to the following:

• Resident
• Home Program Director
• Associate Dean, PGME

3.1.4 Appeal decisions made by the RPC and/or an Ad Hoc Departmental Appeal Committee may be further appealed to the Max Rady College of Medicine Academic Appeals Committee or to the University of Manitoba Senate Appeal Process

3.2 With respect to initiating a Max Rady College of Medicine Academic Appeals Committee appeal, residents are advised to refer to the Max Rady College of Medicine Policy and Procedures on Academic Appeals (Appendix 1)

3.3 With respect to initiating a University of Manitoba Senate appeal, residents are advised to refer to the University of Manitoba, Senate Committee on Appeals Policy and Procedures (Appendix 2)

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POLICY CONTACT

Associate Dean, PGME

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REFERENCES

Office of Fair Practices and Legal Affairs

University of Manitoba – Student Affairs – Behavioural Policies and letter templates

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APPENDICES

Appendix 1: Max Rady College of Medicine Policy and Procedures on Academic Appeals

Appendix 2: University of Manitoba Senate Committee on Appeals Policy and Procedures

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These program-specific materials can be found on Entrada:

• Appeals
• Examinations
• Forms

Access Entrada

These program-specific materials can be found on Entrada:

• Appeals
• Examinations
• Forms

Access Entrada

Policy name	Assessment results
Application and scope	Undergraduate Medical Education (UGME) students
Approved date	May 2020
Review date	February 2025
Revised date	February 2020
Approved by	Progress Committee (December 2019); College Executive Council (January 2020); Senate Committee on Instruction and Evaluation (February 2020); Senate (May 2020)

1. PURPOSE

4.12 Typically within seven (7) working days of ascertaining final examination scores:

FITERS

4.20 Preceptor will complete a FITER for each assigned student as per policy statement 3.1.

This may require coordination of input from multiple preceptors.

4.21 The completed FITER will be available for student review on the curriculum management system as soon as it is submitted.

4.22 Students will complete the student component of the FITER within one (1) working day of receiving the evaluation. Students have the opportunity to comment on the contents of the FITER before it is returned to Undergraduate Medical Education.

4.23 If the FITER is pass the evaluation is complete. If the FITER is a borderline pass or fail the curriculum management system generates an email alert to the Administrator, Clerkship Evaluations, Clerkship Director and Associate Deans of Professionalism, Student Affairs and UGME.

4.24 The Administrator, Clerkship Evaluations will review both scores and the narrative comments and determine appropriate evaluation with the agreement of the preceptor.

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5. REFERENCES

5.1 UGME Policy and Procedures – Examination Conduct

5.2 UGME Policy and Procedures – Deferred Examinations

5.3 UGME Policy and Procedures – Supplemental Examinations

5.4 UGME Policy and Procedures – Promotion and Failure

5.5 UGME Policy and Procedures - Invigilation of Examinations

5.6 UGME Policy and Procedures – Communicating Methods of Evaluation in the Undergraduate Medical Education Program.

5.7 University of Manitoba- Final Examinations and Final Grades Policy

5.8 University of Manitoba- Deferred and Supplemental Examinations Procedures

5.9 University of Manitoba- Final Examinations Procedures

5.10 University of Manitoba- Final Grades Procedures

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6. POLICY CONTACT

Please contact Director, Evaluations with questions respecting this policy.

Policy name	Assignment guidelines
Application and scope	Year I to Year II Undergraduate Medical Education Students
Approved date	August 14, 2020
Review date	May 2024
Revised date	July 31, 2020
Approved by	PSEC (May 2020); Progress Committee (August 2020)

This document provides further information on assignments. It is associated with the following UGME policies:

• Promotion and Failure
• Communicating Methods of Evaluation

1. All assignments are mandatory. Any missing or incomplete assignments will result in an incomplete on the student’s record for the corresponding course. Students are expected to submit all assignments on time, as this is an element of professionalism.

2. A late assignment can be submitted up to three consecutive business days after the original deadline but will receive partial credit:

• First day late = 10% deducted from final assignment mark
• Second day late = 30% deducted from final assignment mark
• Third day late = 50% deducted from final assignment mark

If original mark surpasses the pass mark set by the Course Leader, the student will pass the assignment but the actual mark recorded will be the deducted mark.

3. After the third day, late assignments receive an automatic zero grade and an incomplete on the student’s record.

• Students must submit a reasonable attempt assignment to remove the incomplete from their record. Reasonable attempt to be defined by the Course Leader.

4. Pass mark for assignments is at the discretion of the Course Leader and must be posted in the syllabus

• Students must submit a reasonable attempt at all parts and questions of an assignment or it will be incomplete.
• The Course Leader defines reasonable attempt.
• In case of dispute, assignment sent to the Pre-Clerkship Evaluations

Committee for independent review and final decision.

• If the assignment result is below the set pass mark, it is up to the discretion of the Course Leader if a supplemental assignment or revisions to original assignment are required. Supplemental or revised assignment must receive a pass in order for the incomplete to be removed. Original grade will be retained in the gradebook.

5. Assignment deadlines

• All deadlines and/or timelines for assignments must be published in the syllabus.
• In case of missing/incomplete assignments, students will be contacted and asked to submit their assignment in order to remove the incomplete from their record. Date to be determined by the Evaluations Program Administrator.
• Students who do not submit their assignments will be asked to meet with the Associate Dean, Undergraduate Medical Education.
• Extensions to deadlines may be given at the discretion of the Office of Student Affairs. The deadline date will be discussed with Course Leaders.
• All requests for extensions must be made before the assignment deadline.
• Exceptional, unforeseen circumstances will be considered on an individual basis.
• Assignments will not be accepted past the last day of July.

Policy name	Career development and performance feedback
Application and scope	Applicable to all Geographic Full Time (GFT) or nil-salaried academic appointments in the Max Rady College of Medicine, University of Manitoba
Approved date	December 10, 2013
Review date	Five (5) years from revised date
Revised date	June 19, 2018
Approved by	Dean’s Council, Max Rady College of Medicine: June 19, 2018; Reviewed at Department Heads´ Council, Max Rady College of Medicine: June 22, 2018

1. PURPOSE

1.1 To provide for the regular documented assessment of Faculty Members’ academic and clinical accomplishments, and to support their Career Development and progress towards promotion. This Policy is intended to complement existing performance management processes.

1.2 To provide for the manner by which regular feedback will be provided and received by both Faculty Members and their Department Heads, in order to facilitate a culture of support and development within the College, in accordance with the College’s commitment to equity, diversity and inclusion.

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2. CONTEXT

2.1 Faculty Members governed by this Policy shall ensure compliance with all professional standards, laws and policies applicable to their profession and employment.

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3. DEFINITIONS

3.1 Appeals Process: The process set out in this Policy for Faculty Members to request that a disagreement over Performance Feedback and procedural fairness be reviewed and resolved.

 3.2 Assignment of Duties: The scope of activities that may be set out in a Faculty Member’s letter of offer, letter of agreement, other contract and/or job description, which may, from time to time, be updated or changed by mutual agreement between the College and the Faculty Member so as to ensure certainty regarding their relationship as it relates to the University.

3.3 Career Development: The proactive planning and implementation of action steps towards a Faculty Member’s career goals as mutually agreed upon between the Department, College and the Faculty Member through Performance Feedback.

3.4 College: The Max Rady College of Medicine, University of Manitoba.

3.5 Department: an academic and administrative subdivision of the Max Rady College of Medicine, University of Manitoba established by the Board of Governors, usually on the recommendation of the Senate, for the purpose of conducting teaching and research in specified fields of study.

3.6 Department Head: the head of a Department of the Max Rady College of Medicine within the University of Manitoba, who acts as the chief executive officer of the Department.

3.7 Faculty Member: A Geographic Full Time (GFT) or Nil-Salaried Academic Appointment in the College.

3.8 Geographic Full Time (GFT) Academic Appointment: refers to a faculty member whose professional activities are based at the University of Manitoba’s Max Rady College of Medicine or its affiliated teaching hospitals, who may receive income from professional practice and from sources other than the University and its affiliated teaching hospitals, and who is signatory of a Geographical Full-Time Agreement with the University (the “GFT” Member) and who may only carry on a clinical practice inside University approved facilities.

3.9 Nil-Salaried Academic Appointment: refers to a faculty member whose professional activities may or may not be based at the Max Rady College of Medicine or its affiliated teaching hospitals, who may receive income from professional practice and from sources other than the University and its affiliated teaching hospitals, and who is signatory of a Letter of Offer for Nil-Salaried Appointees with the University. All nil-salaried appointments with rank carry the expectation of contributions to the academic activities of the College in teaching, scholarly activity and/or scholarship (research) and service.

3.10 Performance Guidelines: Guidelines provided on the Rady Faculty of Health Sciences Academic Affairs website, that may be used to guide Career Development and Performance Feedback, which are intended to complement a Faculty Member’s Assignment of Duties, as may be applicable and reasonable in the circumstances.

3.11 Performance Feedback: The regular review, assessment and consideration of the following matters, which are intended to identify a Faculty Member’s strengths and to provide direction for improving his or her future performance - about which both the Faculty Member and his or her Department Head or designate may give and receive feedback:

(a) a Faculty Member’s accomplishments, relating to his or her Assignment of Duties;

(b) the College’s needs; and

(c) the Faculty Member’s documented Performance Feedback history.

3.12 Policy: This Career Development and Performance Feedback Policy.

3.13 Procedures: The procedures and methods by which this Policy is operationalized.

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4. POLICY STATEMENTS

Performance Feedback:

4.1 The College and Faculty Members shall ensure Performance Feedback occurs in accordance with the Procedures.

4.2 Performance Feedback will be both formative and summative and will be documented using, wherever possible, objective criteria.

4.3 Performance Feedback will be taken into consideration when reviewing the Assignment of Duties, as well as letters of agreement, letters of offer, contracts and/or appointments.

Career Development:

4.4 Performance Feedback shall be used to support Faculty Members in their Career Development through candid and constructive feedback and the development of plans intended to meet the needs of both Faculty Members and the College.

4.5 Career Development requires involvement by the College and Department.

4.6 Performance Feedback involves establishing and regularly reviewing career goals to support Career Development.

Performance Guidelines:

4.7 Performance Guidelines may be used as a guide when assessing a Faculty Member’s performance, as applicable to his or her Assignment of Duties.

For Faculty Members with Cross-Appointments:

4.8 For Faculty Members with a cross-appointment to one or more Departments, their Performance Feedback will be conducted in the Department where the primary appointment is held.

4.9 In order to consider the accomplishments of a Faculty Member with a cross- appointment to one or more Departments, the Head of the primary Department (or designate) will consult with supervisors in the other Departments as applicable.

For Faculty Members with a Nil-Salaried Academic Appointment:

4.10 For Faculty Members with a Nil-Salaried Academic Appointment, their Performance Feedback shall be carried out, at minimum, prior to the time of re-appointment.

For Faculty Members Whose Performance Feedback Falls Below Expectations

4.11 A Faculty Member whose Performance Feedback does not meet the satisfactory threshold shall be required to meet with his or her Department Head (and/or designate) to reevaluate his or her Career Development plan to incorporate achievable performance targets for the next year or other shorter time period as required by the Department Head.

4.12 A Faculty Member whose Career Development plan has been reevaluated with supports from the College to enable him or her to perform satisfactorily but continues to have difficulty meeting the established targets, may, where appropriate, have his or her Assignment of Duties amended in order to further enable his or her ability to perform as required.

Ability to Record Disagreement with Performance Feedback:

4.13 In the event a Faculty Member disagrees with what is reflected on his or her documented Performance Feedback, he or she may set out a rebuttal in writing to be appended to the documented Performance Feedback.

Ability to Appeal Matters of Procedural Fairness:

4.14 Meaning of Procedural Fairness: For the purposes of this Policy, references to “procedural fairness” shall mean fairness in how the Performance Feedback process was carried out.

4.15 Ability to Appeal Matters of Procedural Fairness: A Faculty Member who feels that his or her treatment pursuant to this Policy was procedurally unfair may appeal such treatment in writing to the Dean of the College within twenty (20) working days of the completion of the documented Performance Feedback.

4.16 Request for Binding Arbitration: If the matter is not resolved to the satisfaction of the Faculty Member within twenty (20) working days of writing to the Dean, the Faculty Member will then have an additional twenty (20) working days to request that the matter be submitted to binding arbitration.

4.17 Choosing the Arbitrator: One arbitrator shall be chosen by agreement between the College and the Faculty Member to resolve the procedural fairness matter in dispute.

4.18 Arbitrator’s Decision Final: The arbitrator’s decision shall be final and binding upon the College and the Faculty Member.

4.19 Expenses: The College and the Faculty Member shall each be responsible for their own expenses involved in the appeal and arbitration process and any costs for the arbitrator shall be equally shared by the College and the Faculty Member.

4.20 Exclusions to Appeals Process: This appeals process does not apply to the following:

• matters unrelated to procedural fairness;
• matters that may be specifically addressed by other University dispute resolution policies and / or the principles of contract law;
• clinical issues unrelated to the College’s jurisdiction.

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5. GENERAL

In the Event of Conflict with other Policies, Standards and/or Agreements:

5.1 In the case of conflict between this Policy and another policy, standard or agreement, the policy, which creates the higher standard, agreement or requirement shall prevail.

Confidentiality:

5.2 All documents considered pursuant to this Policy are confidential and will be subject to the provisions of The Freedom of Information and Protection of Privacy Act, and The Personal Health Information Act, as applicable.

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6. PROCEDURES

6.1 Performance Feedback Process

1) For GFT Faculty Members: Documented Performance Feedback must be carried out at least once a year, at any point during the year that the GFT Faculty Member and Department Head or designate agree upon, and is conducted for work performed during the preceding year, taking into consideration the career stage of the Faculty Member and the fact that it may take several years to reach career goals.

2) For Faculty Members with a Nil-Salaried Academic Appointment: Documented Performance Feedback must be carried out at minimum, prior to the time of re-appointment at any point during that period, as mutually agreed upon by said Faculty Member and the Department Head or designate, and is conducted for work performed since the most recent appointment.

6.2 Responsibilities of Department Heads: Department Heads shall ensure:

1) Accurate Assignment of Duties: That the Assignment of Duties for each Faculty Member accurately reflects his or her current academic and/or clinical role.

2) Performance Feedback Occurs as Required: That Performance Feedback is provided to Faculty Members on a regular basis through the Performance Feedback process.

3) Supports Provided: That career guidance and mentorship are provided to Faculty Members, including specific strategies and the resources and support necessary to allow Faculty Members to perform their responsibilities with excellence. Further, for Faculty Members whose performance falls below expectations, to ensure that such performance is documented and to inform the Faculty Member, in writing, of any area(s) that require improvement, and to create a development plan with clear objectives to support improved performance in the upcoming year.

4) Department Head Delegation: The responsibilities of the Department Head may be delegated to a Section Head or to a Faculty Member with a recognized leadership role, however the Department Head shall be accountable for ensuring that documented Performance Feedback, is completed for all Faculty Members within his or her Department, and submitted annually to the Dean’s Office for all GFT Faculty Members and at minimum, once prior to the time for re-appointment, for those with Nil-Salaried Academic Appointments.

5) Update of Assignment of Duties: The Department Head shall ensure that a Faculty Members’ Assignment of Duties is updated to accurately reflect the current scope of activities of the Faculty Member.

6.3 Responsibilities of Faculty Members: Faculty Members shall:

1) Participate: Participate in the Performance Feedback process.

2) Comply with Assignment of Duties: Maintain satisfactory performance of his or her Assignment of Duties.

3) Provide Evidence of Performance: Provide evidence of performance (i.e., CV) and input performance data into the Performance Feedback process, when requested.

4) Review Career Goals: Establish, and regularly review and update, career goals and objectives.

5) Follow Through: Follow through on recommendations when opportunities for Career Development have been identified during the Performance Feedback Process.

6.4 Responsibilities of the College: The College must ensure the following responsibilities are carried out in compliance and furtherance of its commitments to equity, diversity and inclusion as set out in applicable policies, from time to time, and in accordance with accreditation requirements. In particular, the College shall:

1) Educate and Support: Provide education and support in developing, implementing and maintaining this Policy and the Performance Feedback process.

2) Support Department Heads: Provide leadership support to Department Heads and designates through all aspects of the Career Development and Performance Feedback process.

3) Support Faculty Members: Provide the resources and support that allow Faculty

Members to perform their responsibilities with excellence.

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7. REFERENCES

7.1 University of Manitoba - University of Manitoba Faculty Association 2017 – 2021 Collective Agreement

7.2 Rady Faculty of Health Sciences Academic Affairs website

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8. POLICY CONTACT

Please contact the Vice-Dean Academic, Rady Faculty of Health Sciences with questions respecting this policy.

Policy name	Computer policy
Application and scope	Undergraduate Medical Education Students
Approved date	February 2021
Review date	February 2025
Revised date	January 2021
Approved by	UGME Management Committee; College Executive Council Senate

1. PURPOSE

The Max Rady College of Medicine has integrated the use of online examinations for all aspects of Undergraduate Medical Education (UGME) Final and Midterm Examinations. It is expected that UGME students will have their own laptop computer to use during examinations. This policy will ensure students have the most current requirements resulting in system compatibility and reduction of errors.

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2. DEFINITIONS

2.1 National Board of Medical Examiners (NBME) Exam – A multiple choice examination developed by the NBME that is administered at the end of the Surgery, Internal Medicine, Obstetrics/Gynecology and Reproductive Sciences, Pediatrics, Family Medicine, and Psychiatry clinical rotations at the Clerkship level of the UGME program. The NBME will recommend a pass mark as an equated percent correct score, and the UGME Program will determine the pass mark every September, based on this recommendation.

2.2 ExamSoft – An examination management system adopted by the Max Rady College of Medicine, which enables students to conduct exams on a personal computer while locking out all other programs and internet access. This system also provides discrete and precise feedback on student results and performance across a range of categories linked to the curriculum.

2.3 Examplify – The application downloaded to a student’s computer that interfaces with ExamSoft.

2.4 ExamSoft Password - A student’s personal ExamSoft password is created by ExamSoft. It is used to access Examplify and the ExamSoft secure website.

2.5 Exam Password - A password assigned to open a specific exam in Examplify. All Students will use the same Exam Password when accessing the same exam in Examplify. Students will be given the password at the beginning of their exam.

2.6 Chief Invigilator (CI) – The person responsible for the administration of the examination who ensures strict compliance with UGME examination policies and procedures and/or NBME testing regulations.

2.7 Chief Proctor – The Chief Proctor is deemed equivalent to the Chief Invigilator as established by the University of Manitoba Registrar’s Office. The term “Chief Proctor” may be used interchangeably with and means “Chief Invigilator” or “Invigilator in Charge”.

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3. POLICY STATEMENTS

GENERAL

3.1 All Med I and Med II summative examinations will be conducted utilizing the Pre-clerkship Examination System.

3.2 Med III and Med IV students will be tested using the Clerkship Examination System at the end of each clinical rotation.

3.3 Any attempt to begin exam early, disable or tamper with security features will be considered a violation of the integrity of the exam.

3.4 This policy will be reviewed on the first anniversary of its original passage and every five years thereafter.

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4. PROCEDURES

RESPONSIBILITY OF A STUDENT

4.1 Review Computer Policy Standard Work (Appendix 1).

4.2 Review Pre-Exam Notification before every exam (Appendix 2)

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5. REFERENCES

UGME – Examination Conduct Policy

University of Manitoba – Use of Computer Facilities Policy

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6. POLICY CONTACT

Please contact Business Manager, UGME with questions respecting this policy.

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Appendix 1: Computer Policy Standard Work

Prior to your exams, you will need to ensure that you are familiar with the Examination Policy

COMPUTER REQUIREMENTS

Before purchasing a new computer/hardware or updating your operating system please refer to the following:

For the latest information regarding computer system requirements it is mandatory that you visit the ExamSoft website.

For the latest information regarding computer system requirements it is mandatory that you visit the NBME website.

TECHNICAL SUPPORT

UGME staff will not provide technical support for Examplify or computer issues during an exam but issues must be presented to the invigilator for record. Problems with computers are not the responsibility of the Max Rady College of Medicine Faculty or Support Staff. Problems with Examplify software need to be addressed by ExamSoft. Problems with your computer must be addressed by your computer vendor/manufacturer/provider. Any of the above issues need to be communicated to the Chief Invigilator for recording purposes.

Should there be an unexpected failure with the student’s computer, UGME does have a small number of computers that can be provided in an emergency. These computers are provided on a first-come, first-served basis and students should not assume that one will be available should it be required.

EXAMPLIFY Support

For the most recent information regarding Examplify support from ExamSoft, please visit their website.

Telephone: 1-866-429-8889
Email: support@examsoft.com

NBME Support

For the most recent information regarding NBME support, please visit their website.

Email: assessmentservices@nbme.org

PRE-CLERKSHIP:

EXAMSOFT EXAMINATION MANAGEMENT SYSTEM

It is the responsibility of the students to familiarize themselves with their equipment, the Examplify software and instructions provided on the ExamSoft website prior to the start of examination. Ensure sufficient time to become familiar with your personal computer and the application.

Pre-Clerkship students must register with ExamSoft at the UGME ExamSoft portal as follows:

• Log in using your Student ID number and password provided at registration
• Download/Install Examplify.
• Restart Examplify. Once registered, students will receive a confirmation email at their University of Manitoba email address.
• Complete a Trial/Test Exam. On completion of the familiarization training during Orientation Week, all students will complete and submit a trial/test exam to provide computer functionality and outline the capabilities of the Examplify system.

Prior to all scheduled exams students must ensure the following:

• Examplify is registered and updated prior to all exam(s). Examplify may be installed on multiple devices for use as a backup. Exam files should only be downloaded to the computer you intend to use on exam day.
• Ensure that the computer meets the specifications outlined on the ExamSoft portal to support Examplify. ExamSoft advises students to utilize mock exams periodically to optimize their testing environments and to adjust their device that they see best fits their preferences.
• Touch screens should be disabled so only the external mouse or trackpad has mouse priority.
• Once Examplify is installed and registered, students shall familiarize themselves with the software by utilizing the built-in Practice Exam feature.
• Ensure that the computer’s battery is charged.
• Disable the sleep/hibernate mode on your computer during the exam. Some computers go into sleep/hibernate mode during extended periods of nonuse. During an exam, it can be difficult to exit this mode. Refer to the instructions for your operating system to modify these settings
• Download the assigned exam. When writing multiple exams, make sure all exams are downloaded prior to the start of the exam.

For days on which an examination is scheduled:

• Students should bring their WIFI-enabled laptop with fully charged battery, power cord, Bannatyne Campus Login and Password (to access the secure UofM –WPA wireless network), student card and ExamSoft password.
• Immediately before Examplify launches an exam, students will be provided with a warning screen indicating that you should not begin the exam until instructed to do so.
• Read the Pre-Exam Notification that appears before the start of the exam. This may contain information pertinent to the examination.
• During the exam, use care when highlighting and deleting.
• Once you are finished your exam, check your answers, save and exit the exam. Computers will seek to acquire a wireless signal. Do not leave the exam room until you have uploaded your exam and you receive a message stating “Your exam has been successfully uploaded.” Failure to upload your exam before leaving the exam room may result in your exam not being graded.
• When writing multiple exams in one sitting they must be completed before you leave. If you exit the exam area before uploading all exams, you cannot re-enter and complete the missing component. Any exams not uploaded before exiting the writing area are scored at 0.

CLERKSHIP:

EXAM DAY PREPARATION FOR NBME

• Computer labs will have setup stations already configured for NBME on site exams.
• Use the instructions that will be provided to you on exam day to download exam.
• The exam is self-timed and will end when you end the exam or the amount of time in the exam expires. A web based exam typically includes an optional tutorial, the exam section(s) and an optional untimed post-test survey
• You will be prompted to read and accept the “Secure Browser Security Notice” to proceed to the Secure Browser download instructions page.

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Appendix 2: Pre-Exam Notification

Today, you are writing Class 20XX xxxxxxx Midterm/Final

This exam is XX hours long, and has XX multiple-choice questions. Please download the exam/s before sign-in. Extra time is not allowed once the exam begins to do this.

If there are additional handouts, please do not write on them, returning to invigilators at the end of the exam.

If you are using a laptop with a touchscreen function, please make sure you double check your answers before submitting the exam or disable this function.

Pencil cases, other pouches, and containers are discouraged. Simple calculators are allowed (no internet functioning, no Apple watches, etc.). Please show your calculator to an invigilator before proceeding to your seat. The ExamSoft calculator is enabled as well.

Hats, headphones or ear buds are not allowed. Ear plugs are allowed – please show them to an invigilator before using. No cell phones or other electronic devices are permitted when writing the exam. Time is displayed on the overhead screen after the exam begins. You can also use the time reminder within the Examplify system.

Optional: you may provide comments and feedback on questions at the bottom of each question. No extra time is given for this, so make sure you manage your time accordingly. These comments are provided to the course leader after each exam.

In accordance with the Examination Conduct policy, no student may enter the examination after the first half hour. Depending on how many students remain with ten minutes left, invigilators will decide if those who are done can leave before the official end of the exam.

In order to maintain a quiet environment for all students, when you have finished the exam, please quietly leave the immediate area outside of the space.

When you have completed the exam, please display the confirmation screen of your exam upload to an invigilator before leaving. If there is an issue with your computer, please contact an invigilator for assistance.

Policy name	Conflicts of interest in student academic assessment or advancement
Application and scope	Undergraduate Medical Education (UGME) students
Approved date	February 2018
Review date	January 2023
Revised date	January 2018
Approved by	College Executive Council, Max Rady College of Medicine

1. PURPOSE

1.1 Accreditation standard 12.5 of the Committee on Accreditation of Canadian Medical Schools (CACMS) and Liaison Committee on Medical Education (LCME) provides: 12.5 Non-Involvement of Providers of Student Health Services in Student Assessment: The health professionals who provide health services, including psychiatric/psychological counseling, to a medical student have no involvement in the academic assessment or promotion of the medical student receiving those services. A medical school ensures that medical student health records are maintained in accordance with legal requirements for security, privacy, confidentiality, and accessibility.

1.2 The purpose of this policy is to ensure that individuals that have provided, or currently provide, health services to a medical student, or have another relationship with a medical student that may be considered a conflict of interest, have no influence on the academic assessment or promotion of that medical student.

1.3 This policy is supplemental to the University of Manitoba Conflict of Interest Policy and Procedures. It is not intended to act as a substitute or duplicate forum to address issues over which the University of Manitoba Conflict of Interest Policy has jurisdiction.

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2. DEFINITIONS

2.1 Academic Assessment or Advancement- Any academic, clinical or in-person assessment of a Medical Student including without limitation assessment in courses, modules, or rotations; midpoint in-training evaluations (MITER); final in-training evaluations (FITER); or recommendations/decisions respecting Medical Student promotion or graduation.

Exclusion: For the purpose of this policy, objective forms of assessment (e.g. multiple choice exams) are not considered Academic Assessment or Advancement. For objective forms of assessment, the assessment should proceed as planned.

2.2 Conflict of Interest- Specific to this policy, a situation where:

a) a health professional who provides, or has provided, health services, including without limitation psychiatric/psychological counseling, to a Medical Student; or

b) a family member of a Medical Student (e.g. 1st degree relative; aunt or uncle); or c) a spouse of a Medical Student; becomes involved in the Medical Student’s Academic Assessment or Advancement.

2.3 Medical Student- A student registered in the UGME program at the Max Rady College of Medicine, University of Manitoba.

4.4 For forms of Academic Assessment or Advancement in which there may be potential for subjectivity in the assessment, the course administrator shall arrange for an alternative assessment to be made.

Reactive Disclosure – Conflict of Interest

4.5 Preceptors who identify a perceived or actual Conflict of Interest while Academically

Assessing or Advancing a Medical Student shall cease the assessment immediately and inform one of: the Rotation Director, the Director, Clerkship or the Associate Dean, UGME.

4.6 Medical Students who identify a perceived or actual Conflict of Interest while being Academically Assessed or Advanced shall inform the preceptor who in turn shall cease the assessment. Both parties shall inform one of: the Rotation Director, the Director, Clerkship, or the Associate Dean, UGME of the occurrence.

4.7 For forms of Academic Assessment or Advancement in which there may be potential for subjectivity in the assessment, the individual notified above shall arrange for an alternative assessment to be made.

Post-Assessment Disclosure – Conflict of Interest

4.8 Medical Students who identify a perceived or actual Conflict of Interest after having been

Academically Assessed will be assigned the grade submitted by the preceptor. Should a Medical Student be dissatisfied with the assigned grade, the case will be reviewed on an individual basis; as well, the Medical Student may access the appeal mechanisms pursuant to the UGME Student Appeals Policy.

Committee Member – Conflict of Interest

4.9 Any member of a Committee involved in the Academic Assessment or Advancement of a

Medical Student (e.g. Progress Committee) who has a perceived or actual Conflict of Interest shall declare the Conflict of Interest, recuse himself/herself from that portion of the meeting, and abstain from commenting or voting on the Medical Student’s Academic Assessment or Advancement.

4.10 If quorum cannot be obtained due to multiple Conflicts of Interest, the Associate Dean, UGME, shall temporarily appoint faculty member(s) to serve as designate(s) for the Committee member(s) who declared a Conflict of Interest. The designate(s) are authorized to consider and vote upon the Academic Assessment or Advancement of the Medical Student where the Conflict of Interest was declared. The designate(s) will be recused from the Committee immediately after.

Medical Student Health Records

4.11 The UGME office shall store any Medical Student health-related information voluntarily submitted by a Medical Student in the Medical Student’s Student Affairs file and not in the Medical Student’s academic file.

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5. POLICY CONTACT

Please contact the Associate Dean, Undergraduate Medical Education, Max Rady College of Medicine with questions regarding this document.

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6. REFERENCES

University of Manitoba Conflict of Interest Policy

Policy name	Essential skills and abilities (technical standards) for admission, promotion and graduation in medicine
Application and scope	Candidates for admission, promotion or graduation in the MD and the MPAS programs
Approved date	April 2009
Review date	One year from the last revised date
Revised date	June 26, 2019
Approved by	Reviewed at Dean’s Council, Max Rady College of Medicine: June 19, 2018; Reviewed at MPAS Curriculum Committee: June 22, 2018; Reviewed at UGME Curriculum Executive Committee: July 3, 2018; College Executive Council, Max Rady College of Medicine: August 21, 2018; Faculty of Graduate Studies: February 14, 2019; Senate: June 26, 2019

1. PURPOSE

Please contact the Associate Dean, Undergraduate Medical Education or the Director, Master of Physician Assistant Studies with any questions respecting this policy.

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APPENDIX

These program-specific materials can be found on Entrada:

• Appeals
• Examinations
• Forms

Access Entrada