DHA: MEDICAL/DENTAL STAFF RE-APPOINTMENT APPLICATION Part 1

Transcription

1 DHA: MEDICAL/DENTAL STAFF RE-APPOINTMENT APPLICATION Part 1 IWK Health Centre Annapolis Valley Health Cape Breton Health Capital Health Colchester East Hants Health Cumberland Health Guysborough Antigonish Health Pictou County Health South Shore Health South West Health Please submit this completed application along with a copy of your current: Nova Scotia Medical License, and proof of Medical Protective Insurance (CMPA Membership Update) 1. CONTACT INFORMATION NAME: Office Address: LATE APPLICATIONS WILL BE SUBJECT TO A LATE FEE Office Telephone: Cell: Other Home Address: Home Telephone: Office Fax: Office Emergency Number: 2. DEPARTMENT PRIVILEGES: MAIN DEPARTMENT where you hold Main Dept Privileges Category OTHER DEPT(s) IN NS where you hold Privileges Category (DHA ZONE / IWK) 3. SITE INFORMATION: MAIN SITE where you hold Main Site Privileges Category OTHER SITE(s) IN NS where you hold Privileges Category (DHA ZONE / IWK) 4. PRIVILEGES: a) Please list any changes you would like to make to your : b) Did you add any new procedures to your since your last (re-) application? Yes No

2 Page 2 c) What process did you follow to obtain competency? (attach certificates) Certifications (please indicate your most recent certification date) Day/Month/Year a) BCLS (Basic Life Support) b) ACLS (Advanced Cardiac Life Support) c) PALS (Pediatric Advanced Life Support) d) ATLS (Advanced Trauma Life Support) e) NNRC (Neonatal Resuscitation Course) f) ALSO/ALARM (Obstetrical Risk Management) g) AIME (Advanced Airway Management) 5. Since your last appointment: Are you currently the subject of any complaint, investigation or other proceeding in relation to your conduct, competence, character, capacity or fitness to practice by a regulatory body or by any entity? Regardless of the outcome, have you ever been the subject of a review of your conduct, competence, character, capacity or fitness to practice whether arising from a complaint or otherwise? Have you ever, in expectation of, or during the course of, any investigation or disciplinary proceeding, voluntarily entered into an undertaking to restrict or to refrain from practice? Have you ever pleaded guilty to, or been found guilty of, or accepted a regulatory settlement or sanction acknowledging professional misconduct, conduct unbecoming, or like charges? Have you ever been found to be incompetent or incapacitated? Has there ever been any civil proceeding, legal action, insurance or other claim that arose or was alleged to arise in whole or in part from your practice of medicine or your medical professional activities? Is there now, or are you aware of any pending civil proceedings, legal actions, insurance or other claims that arose or were alleged to arise in whole or in part from your practice of medicine or your professional activities?

3 Page 3 Has a court ever made a finding against you in respect of a civil proceeding, legal action or claim that was in any way related to your practice of medicine or your professional activities? Have you ever agreed to a settlement as a means to resolve civil proceedings or in relation to any investigation, proceeding or disciplinary action with respect to your professional conduct, competence, character, capacity or fitness to practice? Have you been absent from practice for three (3) continuous months or longer for any reason? Have you ever been denied in a hospital or other health facility? Have you ever voluntarily relinquished or changed your or resigned from a hospital, health authority or other health facility, either during or subsequent to an inquiry, investigation or review that was in any way related to your professional conduct, competence, character, capacity, fitness to practice or any other aspect of your medical practice? Have you ever resigned from a hospital or other health facility while disciplinary action was pending? Have you ever withdrawn an application for at a hospital, health authority or other health facility? Have you ever had your suspended, reduced or changed by a hospital or other health authority or facility for cause other than medical records? Are you now or have you ever been the subject of any type of investigation, inquiry, review or action by a hospital, health facility, or any other place of employment relating to your conduct, competence, character, capacity, fitness to practice or any aspect of your medical practice? Have you ever been restricted in your prescription of opiates or other controlled drugs? Are you now subject to any contract, agreement, undertaking or obligation with any medical licensing authority, health authority or facility or other regulatory or governmental body that might be relevant to your application for a license to practice medicine in the province of Nova Scotia? Is there any event, circumstance, condition or matter not disclosed in your answers to the preceding questions in respect of your conduct, competence, character, capacity or fitness to practice that might be relevant to your application for registration/licensure to practice medicine in the province of Nova Scotia?

4 Page 4 Have you left or been dismissed from your employment as a result of concerns relating to your conduct or concerns relating to matters of professional competence? Have you had your to practice in a hospital or health authority revoked, withdrawn, altered in any way or not renewed as a result of concerns relating to your conduct or professional competence? Have you resigned your district or hospital while such actions were pending? HEALTH AND FITNESS TO PRACTICE Have you ever or do you presently suffer from any condition that may limit your ability to practice or constitute a risk to patients? Do you have a blood-borne communicable disease or condition which, by its nature, could place your patients at risk if there were an inadvertent exposure? Have you ever taken a medical leave of absence of more than three days from a medical school, a postgraduate medical training program or any professional position or employment? Have you ever been advised by a treating physician to restrict your practice of medicine? Have you ever been or are you now abusing, dependent on, or addicted to alcohol or a drug? Have you ever or are you now being treated for abuse of, dependence on, or addiction to alcohol or a drug? If yes to any of these questions, provide details under separate cover, marked confidential, to the Chair, Credentials Committee, DHA/IWK. 6. Committee Work: The Medical/Dental Staff Rules and Regulations require members of the Medical/Dental Staff to serve on a committee(s). Please write in the committees you currently serve on and your preference of committees you would like to serve on. Current Membership Preferred Membership

5 Page 5 7. CME Requirements: *Please provide details of CME activities on separate sheet of paper. Specialists: The standard for MOCERT is 400 hours for five years. This amounts to 240 hours per three years, of which only 60 hours may be category 2. Family Physicians: The standard for CME hours are 250 hours for five years. This amounts to 150 hours per three years, of which only 75 hours may be Mainpro M2 (selfdirected reading and non-accredited activities). Dentists: The standard for CDE hours are 90 hours for three years. Courtesy Privileges for OR Assists: CME activities are encouraged; however, not required for this category of. 8. Other: a) Are you planning a sabbatical or leave of absence? Yes No If so, when? b) Any planned retirement or slow down date? Yes No If so, when?