Locum Placement Tracking Form

Locum Placement Tracking Form

You can use this form to gather data and help you track them easily when someone temporarily fulfills the duties of another or so called Locum. Form Preview
  • MABC Rural Midwifery Locum Program

    Placement Tracking Form
  • This form provides the MABC Rural Midwifery Locum Program with a detailed record of the agreement between a Locum and Host midwife regarding the dates of a coverage period.

    Locum midwives are responsible for ensuring that the details they submit are agreed to by the Host midwife.

    This form determines the amount that host midwife will owe and the amount the locum will be paid for this coverage period according to the Rural Midwifery Locum Program Policy Statement (March 2015).  Once submitted, both locum and host will receive a confirmation email with all details of the agreement, for personal records.

    If you have any questions or concerns, please contact Sunya Lai Thom (RMLP Program Manager) at programs@bcmidwives.com or 604-736-5976. 

    Please ensure that all information contained in this form is complete and accurately reflects the locum/host agreement prior to submission.


  • LOCUM INFORMATION

  • HOST INFORMATION

  • COVERAGE PERIOD INFO

  • Orientation Day – A paid orientation day is mandatory for each coverage period. Please provide the date of the scheduled orientation.

  •  -  - Pick a Date
  • Coverage Dates – Provide the dates that you will be providing coverage for the host midwife inclusive of any paid days off agreed to.

  •  -  - Pick a Date
  •  -  - Pick a Date
  • Paid Days Off – If your coverage period will include any paid days off, please provide the details below. 

  • PAYMENT METHODS

    Please confirm the method of payment prefered by both locum and host midwifes. This will change the total amount paid or owed.

  • FEE CALCULATION

  • CONFIRMATION OF AGREEMENT

  •  
    • OFFICE USE ONLY  
    • RMLP Subsidy Amounts

      _______________________________________________________

    • Host Payment Information

      _______________________________________________________

    •  -  - Pick a Date
    • Locum Payment Information

      _______________________________________________________

    •  -  - Pick a Date
    • Should be Empty: