Employer Declaration

Practice name *

Practice location *

Practice group *

If 'other', please specify

I am a *

Practice manager Planning to supervise student Director Other

If you selected 'Other' please state below

First name *

Last name *

Email *

I confirm I have read and understood the guidance provided in the CLiP Employer Handbook (available on the College website):

I confirm the practice will

Allow the student use of a consulting room for 20 hours per week
Provide all the required equipment for the student to use
Arrange the required working hours and learning time for the student
Allow the supervisor or supervisory team enough time to carry out their responsibilities
Maintain appropriate Public Liability insurance

I confirm the practice will commit to their allocated student

I agree to the data I provide in this form to be held by The College of Optometrists. It may be shared with my employer group (if applicable) in the need to evidence this declaration

Signature *

Date *

Please tick

Clinical Learning in Practice (CLiP)

Employer Declaration

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