APPLICATION COVER PAGE General Internal Medicine.

Transcription

1 APPLICATION COVER PAGE General Internal Medicine PLEASE SEND YOUR COMPLETED FORMS TO: Postal Address: 774 Echo Drive Ottawa, ON K1S 5N8 Fax: PLEASE ATTACH THE FOLLOWING DOCUMENTS TO YOUR APPLICATION: Copy of your CV Proof of licensure in a Canadian province Proof of 24 months of training in the subspecialty of General Internal Medicine as well as details of the training rotations (for those in practice less than 5 years) If you participate in a GIM call rota: attach a call schedule that demonstrates your participation in GIM call from the last year. (Please indicate your name on the call schedule) IMPORTANT INFORMATION : The deadline to submit your application for certification via the Practice Eligibility Route for Subspecialists is August 31 st of the year before you wish to be examined. o Click here for current assessment fees o Should you submit your application after the deadline, you will be subject to a late penalty fee Please ensure that you have reviewed the subspecialty s criteria before submitting your application

2 Form A: PERSONAL DETAILS IMPORTANT NOTES You will receive confirmation that your application has been received. The Royal College will remain in contact with you via . Please ensure that we have your current address on file. Applications will be reviewed in the sequence in which they are received. This process will take several months. You will be contacted directly if we require any additional information. Subspecialty: Exam Year: PERSONAL DETAILS 1. Identification Title: Dr. Dr Dre Sex: Male Female Language: English French Date of Birth: / / DD MM YY Surname: Given Name: Middle Name: Royal College ID (if applicable): 2. Contact Information Home Address Business Address Street no. and name: Apt no: City: Province: Postal Code: Home phone Business phone Cell phone Home phone Business phone Cell phone Home Business Home Business CONTACT INFORMATION Web: Mail: 774 Echo Drive Phone: Ottawa, ON Fax: K1S 5N8 persub@royalcollege.ca Page 1 of 1

3 Form B: CREDIT CARD AUTHORIZATION FORM CREDIT CARD AUTHORIZATION FORM ONE TIME USE ONLY I authorize the Royal college to charge the non-refundable assessment fee to my credit card for the amount indicated. NAME OF APPLICANT: (PLEASE PRINT) Amount $ Mastercard Visa American Express Card Number: Expiry Date (MM/YY): / Cardholder s name: (PRINT CLEARLY) Cardholder s signature: **Please note:the Royal College will charge the credit card in Canadian dollars. Royal College use only ID number: Specialty Name : Specialty Code: Financial Rev Code: Agent initials: Page 1 of 1

4 Form C: Form B: DECLARATION CREDIT CARD AUTHORIZATION FORM DECLARATION FORM C All personal, biographical and academic information relating to your training is confidential and is provided for the recognized legitimate use by the officers and staff of the Royal College. The Royal College may receive and exchange any and all information, which may be requested relative to my training history, credentialing, examination eligibility, scope and competencies in practice from my Chief of Staff, Head of Department or any other supervisor to whom I report in a Canadian institution; the Medical Regulatory Authority in the Canadian province in which I practice; and any and all institutions where I undertook my postgraduate medical education training. I understand that any misinformation in this application or in any document at any time, provided by me in support of my application, may lead to refusal of my application or withdrawal of eligibility previously granted. I agree to abide by the decisions of the Royal College of Physicians and Surgeons of Canada. Signature Date Page 1 of 1

5 Form D: SCOPE OF PRACTICE General Internal Medicine DEFINITION OF A SCOPE OF PRACTICE: i) Every physician s scope of practice is unique. ii) A physician s scope of practice is determined by the patients the physician cares for, the procedures performed, the treatment provided, and the practice environment. iii) A physician s ability to perform competently in his or her scope of practice is determined by the physician s knowledge, skills and judgment, which are developed through training and experience in that scope of practice. Please spell out any abbreviations. Identification: Surname: Given name: 1. What year did you receive Royal College certification in Internal Medicine? 2. What year did you start practicing General Internal Medicine? Please do not include time spent in practice during a Fellowship 3. What percentage of your clinical practice is composed of General Internal Medicine? 4. Provide a brief narrative summary of your clinical practice. Include if your practice has changed over time and how these changes have occurred. Attach a separate page if necessary 5. Do you participate in a GIM Call Rota? Yes No Attach a call schedule that demonstrates your participation in GIM call from the last year. (Please indicate your name on the call schedule). Page 1 of 6

6 Form D: SCOPE OF PRACTICE General Internal Medicine If you answered yes to question 5 please describe: Attach a separate page if necessary a) Frequency of call: b) Profile of patients seen on call: c) Where the patients are referred from: d) Any restrictions on types of patients that can be referred: e) Your access to other subspecialists (if any) while on call: 6. Do you interpret (including while on call): a) Electrocardiograms (ECGS) Yes No b) Arterial Blood Gas (ABGs) Yes No c) Chest Radiograph Yes No Page 2 of 6

7 Form D: SCOPE OF PRACTICE General Internal Medicine 7. What is your involvement in each of the following practice environments? Patient care (direct and indirect) Practice setting: % of Clinical Time Spent in Setting a) Direct GIM Inpatient Care b) Consultations to Inpatients c) Ambulatory Care d) Critical Care/ICU Setting e) Other please explain: 8. List procedures that you perform in your practice and the frequency per year that you perform them: Attach a separate page if necessary Procedure: Frequency: 9. List the top ten diagnoses and frequency of each of these diagnoses in the last 100 patients that you have seen in any setting: Attach a separate page if necessary Page 3 of 6

8 Form D: SCOPE OF PRACTICE General Internal Medicine Diagnosis: Frequency: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 10. Briefly describe your involvement in General Internal Medicine teaching/education: Attach a separate page if necessary Page 4 of 6

9 Form D: SCOPE OF PRACTICE General Internal Medicine 11. Briefly describe your involvement in General Internal Medicine administration: Attach a separate page if necessary 12. Briefly describe your involvement in General Internal Medicine Research/ Scholarly Activities: Attach a separate page if necessary Page 5 of 6

10 Form D: SCOPE OF PRACTICE General Internal Medicine 13. Briefly describe your involvement in General Internal Medicine Advocacy/Policy and Public Health/Community Outreach: Attach a separate page if necessary Page 6 of 6

11 PER-sub: Multi-source Subspecialists Feedback (PER-sub) (MSF) Child and Adolescent Psychiatry (CAP) Form E: REFEREE VERIFICATION (RV) General Internal Medicine Please provide the names of physicians who have knowledge of your professional practice. They will be contacted and asked to provide feedback on your practice. (i.e.: chief of staff, head of department etc ) A release of information form for each of your referees must be appended to this form (see Form F). Applicant Identification: Surname: Given name: A: Identification of Referee #1 Title/ Position: Dr. Dr Dre Name: Contact Information for Referee #1 Street no. and name Apt no. City Province Country Postal Code ext.( ) Telephone Fax B: Identification of Referee #2 Title/ Position: Dr. Dr Dre Name: Contact Information for Referee #2 Street no. and name Apt no. City Province Country Postal Code ext.( ) Telephone Fax 1 of 1

12 PER-sub: Multi-source Subspecialists Feedback (PER-sub) (MSF) Child and Adolescent Psychiatry (CAP) Form F: RELEASE OF INFORMATION FOR REFEREE AUTHORIZATION FOR RELEASE OF INFORMATION FOR REFEREE From: Please print your name To: Royal College of Physicians and Surgeons of Canada I, THE ABOVE-NAMED PHYSICIAN, HEREBY AUTHORIZE: Name of Referee To release any and all information which may be requested relative to my training history, credentialing and examination eligibility. You may furnish copies of any and all records in my file. This authorization shall continue until revoked by me in writing. A photocopy of this authorization shall serve in its stead. Dated at: City and Province / Territory Dated: (Day) (Month and Year) Applicant s signature Applicant s name Witness signature Witness name 1 of 1

13 PER-sub: Multi-source Subspecialists Feedback (PER-sub) (MSF) Child and Adolescent Psychiatry (CAP) Form F: RELEASE OF INFORMATION FOR REFEREE AUTHORIZATION FOR RELEASE OF INFORMATION FOR REFEREE From: Please print your name To: Royal College of Physicians and Surgeons of Canada I, THE ABOVE-NAMED PHYSICIAN, HEREBY AUTHORIZE: Name of Referee To release any and all information which may be requested relative to my training history, credentialing and examination eligibility. You may furnish copies of any and all records in my file. This authorization shall continue until revoked by me in writing. A photocopy of this authorization shall serve in its stead. Dated at: City and Province / Territory Dated: (Day) (Month and Year) Applicant s signature Applicant s name Witness signature Witness name 1 of 1

14 Form G: Subspecialists (PER-Sub) PRACTICE & TRAINING DETAILS Identification: Surname: Given name: CURRENT PRACTICE DETAILS Subspecialty: What date did you start practicing in the subspecialty listed above: / Do not include fellowship training MM YY What date did you start practicing in the subspecialty in Canada: / MM YY What percentage of time do you spend practicing the in the subspecialty listed above: % Additional Comments: POSTGRADUATE MEDICAL EDUCATION HISTORY Only complete if you have less than five years in practice. Training in the subspecialty of: Residency Fellowship Other (please specify): Start of training date: End of Training date: Total # months = Name of institution: Attach proof of completion of training document (e.g. diploma, transcript) Any additional training/experience relevant to the subspecialty: Training in the subspecialty of: Residency Fellowship Other (please specify): Start of training date: End of Training date: Total # months = Name of institution: Attach proof of completion of training document (e.g. diploma, transcript) Page 1 of 1

15 Subspecialists (PER-sub) Last Month s Call Schedule Cover Page * If you participate in a General Internal Medicine call rota, please attach last month s call schedule behind this cover page

16 Subspecialists (PER-sub) CURRICULUM VITAE (CV) Cover Page *Please attach your Curriculum Vitae (CV) behind this cover page

17 Subspecialists (PER-sub) Provincial License Cover Page *Please attach a copy of your license to practice behind this cover page

18 Subspecialists (PER-sub) Documentation of Subspecialty Training Cover Page *If you have been in subspecialty practice for less than 5 years, please attach official documentation of your subspecialty training behind this cover page