Locum Placement Tracking Form

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
First Name (Locum)
Last Name (Locum)
Phone Number (Locum)
Format: (000) 000-0000.
E-mail (Locum)
HOST INFORMATION
First Name (Host)
Last Name (Host)
Phone Number (Host)
Format: (000) 000-0000.
E-mail (Host)
Host Community Name
Community Type
auto-filled from Community list
COVERAGE PERIOD INFO
Orientation Day – A paid orientation day is mandatory for each coverage period. Please provide the date of the scheduled orientation.
Date of mandatory Orientation Day
MonthDayYear
Coverage Dates – Provide the dates that you will be providing coverage for the host midwife inclusive of any paid days off agreed to.
First Day of Coverage
MonthDayYear
Last Day of Coverage
MonthDayYear
Paid Days Off – If your coverage period will include any paid days off, please provide the details below.
Will you receive any paid days off during this coverage period?
How many paid days off will you receive during this coverage period?
Date of day off #1
MonthDayYear
Date of day off #2
MonthDayYear
Date of day off #3
MonthDayYear
Date of day off #4
MonthDayYear
Date of day off #5
MonthDayYear
Date of day off #6
MonthDayYear
PAYMENT METHODS
Please confirm the method of payment prefered by both locum and host midwifes. This will change the total amount paid or owed.
LOCUM – How would the locum prefer to receive payment?
Locum e-transfer amount?
HOST – How would the host prefer to submit payment? (be sure to confirm this with the host prior to submitting this form)
host CC amount?
FEE CALCULATION
Ready to calculate?
Total owed to Locum (Rural)
Total owed to locum (Remote)
Total owed by Host (Rural)
Total owed by Host (Remote)
Total RMLP subsidy (Rural)
Total RMLP subsidy (Remote)
CONFIRMATION OF AGREEMENT
By submitting this form, you are confirming that the details described in this form have been agreed to by both yourself (locum midwife) and the host midwife described above.
- RMLP Subsidy Amounts
  _______________________________________________________
- Orient Days
- Total Work Days
- Days Off
- R Coverage $
- RR Orient $
- RR Coverage $
- RR Days Off $
- Host Payment Information
  _______________________________________________________
- Payment received from Host?
- Host payment date
  MonthDayYear
- Host payment details
- Locum Payment Information
  _______________________________________________________
- Payment sent to Locum?
- Locum payment date
  MonthDayYear
- Locum payment details
- Should be Empty:

MABC Rural Midwifery Locum Program

LOCUM INFORMATION

HOST INFORMATION

COVERAGE PERIOD INFO

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