eligibility review for physician seeking to … screening...eligibility review for physician seeking...

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ELIGIBILITY REVIEW FOR PHYSICIAN SEEKING TO PRACTICE AS A FAMILY PHYSICIAN

Have you previously been registered in Saskatchewan? _____ Yes _____ No If you answered “Yes” to the above, please fill out Sections, 1, 4 (if applicable) and 5 through 9. Are you planning on working in Saskatchewan for longer than 30 days? _____ Yes _____ No

Please describe your practice plans or intentions:

__________________________________________________________________________________________ __________________________________________________________________________________________ Region you are applying to (if applicable):________________________ Contact person (if applicable):__________________________________ Have you been in contact with Saskdocs? _____ Yes _____ No Have you completed a pre-licensure assessment in any Canadian jurisdiction? _____ Yes _____ No If yes – please identify the program and the date completed: Program: _________________________________________________________________________________ Date completed: ________________________

Section 1 – IDENTIFICATION

Date of Birth: Day _________ Month ___________________ Year _______________

Gender: _____ Male _____ Female

Are you a Citizen or Permanent Resident of Canada? _____ Yes _____ No

Names: Surname (or Family Name) ______________________________________________________________ Given Name (commonly used First Name) _______________________________________________________ Enter any other surnames and given names as they appear on documents used to support an application for licensure:

Surname Given Names

______________________________________ ___________________________________

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Surname Given Names

_____________________________________ __________________________________

_____________________________________ __________________________________

Mailing Address: Street Address _______________________________________________________________________ City/Town __________________________________________________________________________ Province/State _________________________ Country __________________________________ Postal/Zip Code _________________________ Telephone Number: _____________________ Cell phone Number: _____________________ Fax Number: ___________________________ Email address (please provide the one that is used most often and checked most frequently):

____________________________________________________ MINC Number - (if known) ____________________________________________ PCRC number – (if known)_____________________________________________ Note: If you do not currently have a PCRC Account you should exit now, establish a PCRC account and pass the Medical Council of Canada Evaluating Examination

Section 2 – CANADIAN LICENSURE HISTORY Are you currently registered in another Canadian jurisdiction? _____ Yes _____ No If so, please name jurisdiction____________________________________________________________ Are you currently registered for independent practice? _____ Yes _____ No What type of licence do you currently have _________________________________________________

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Does your licence have any restrictions or conditions? _____ Yes _____ No If Yes, please list:

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ You should be advised that the College may require you to complete an authorization form to permit the College to obtain additional information related to your medical practice.

Section 3 - UNDERGRADUATE MEDICAL EDUCATION Name of your medical degree (MD etc): ___________________________________________________ Month/year the Medical Degree was granted: ______________________________________________ Name of University granting the Medical Degree: ___________________________________________ Mailing Address of University: __________________________________________________________________________________________ __________________________________________________________________________________________ Country in which University is located: __________________________________________

Dates which you attended university:

Start Date: _________________________

End date: __________________________

Full Name as it appears on your Medical Degree or Diploma: Surname: __________________________________

Given Name: ______________________________

Section 4 – POSTGRADUATE MEDICAL EDUCATION: University or Medical School __________________________________________

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Hospital: __________________________________________________________ Dates: From _____________________ to _____________________ Enter each rotation on a separate line in the chart below. We require a minimum of: 8 weeks internal medicine 8 weeks general surgery 8 weeks obstetrics/gynecology 8 weeks pediatrics Some psychiatry training Discipline/Rotation Start Date End Date Number of

Weeks Hospital or Medical School

Was your training performance in all years rated as satisfactory by your Program Director(s)?

_____Yes _____ No

If “No” provide a comprehensive summary of the circumstance:

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Note: Applicants who currently hold CCFP certification or who have a letter of CCFP eligibility from the College of Family Physicians of Canada are not required to list rotations. Please proceed to "other postgraduate training" on page 5.

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__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Include the name and contact information for the Program Director(s) involved:

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Document all other postgraduate training or residency training that you have completed or are in the process of completing: Program Name Start Date End Date Number of

Weeks Hospital or Medical School

Section 5 – PRACTICE HISTORY

A. Currency of Practice:

Have you been in independent practice as a family physician during the past 3years? _____ Yes _____ No Have you been in formal program of postgraduate training in the last three years? _____ Yes _____ No If you have not been engaged in independent practice as a family physician or in a postgraduate training program you should exit the application and apply again once you meet currency of practice requirements.

B. Practice History

Complete your practice history beginning with your positions held chronologically from the date you completed your medical degree to the present. You must include the name of every location in which you have practiced medicine, including training, clinical fellowships, research fellowships, etc. Incomplete applications will be rejected.

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A brief description of your practice ____________________________________________

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Start Date _______________________ End Date _______________________

Hospital or Clinic ___________________________________________________________ ∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞ Location _________________________________________________________________


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Hospital or Clinic ___________________________________________________________ ∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞

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Hospital or Clinic ___________________________________________________________ ∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞

Are there any periods of time since completing your medical degree during which you did not practice

medicine? _____ Yes _____ No

You must provide an explanation for all gaps in practice. Incomplete documents will be rejected. If there are any periods of time in which you did not practice medicine, list those periods of time, explain why you were not practicing during this time, and provide a description of what you were doing during this period.

∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞ Dates for which you were not practicing: Start Date: _____________ End Date: ________________

Reason for not practicing ____________________________________________________________

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Description of what you were doing during this period: ____________________________________

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Section 6 – CERTIFICATIONS

____ CCFP date granted: ____________________ ____ Diplomate in Family Medicine, American Board of Medical Specialties date granted: _________________ ____ M.Fam. Med date granted: ____________________ ____ FRACGP date granted: ____________________ ____ Certification from the JCPGTGP date granted: ____________________

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____ CCFP Eligible date: ____________________

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____ Certificate of Completion of Training or a Certificate of Equivalence from the Postgraduate Medical and Training Board date granted: __________________

____ ACLS (list currency date) ______________________ ____ PACLS (list currency date) ______________________

List any other qualifications relevant to your practice of family medicine that you hold and the date that this was granted:

_____________________________________________________________________________ _____________________________________________________________________________ Have you submitted your training for review by the College of Family Physicians of Canada?

_____ Yes _____ No If yes, at what stage is that review and what ruling, if any, have you received from the College of Family Physicians of Canada?

_____________________________________________________________________________ _____________________________________________________________________________

Have you been granted registration on the general practice or family practice registry by any licensing authority?

_____ Yes _____ No If yes, please include on the list requested in Section 10, Question 23. List any other qualifications relevant to your practice of medicine in a specialty that you hold and the date that this was granted: Name of Qualification or Credential

Date Obtained Name of Institution or University Awarding Qualification

Comments

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Name of Qualification or Credential

Date Obtained Name of Institution or University Awarding Qualification

Comments

Section 7 – MEDICAL LICENSING EXAMINATIONS (check all that apply):

Examination Date Score Passing Score MCCEE MCCQE 1 MCCQE 2 USLME 1 USLME 2 CK USLME 2 CS USMLE 3 Other (list) Other (list) Other (list) Other (list) Other (list)

Section 8 – LANGUAGE PROFICIENCY

You require one of the following examinations unless you meet the criteria set out in the explanation below:

TOEFL Score: _________ Date taken:______________

(CPSS requires a minimum of 24 in each of the four components AND a total score of 100, expires after two years)

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Listening score _____________ Reading score ______________

Writing score _______________ Speaking score ______________

Total score _________________

IETLS Score: __________ Date taken: ____________

(CPSS requires a minimum of 7.0 in each of the components, expires after two years)

Listening score _____________ Reading score ______________

Writing score _______________ Speaking score ______________

Total score _________________ Note: Candidates are exempted from English language proficiency testing if their medical education and patient care experience were in one of the following countries that have English as a first and native language: Australia Bermuda British Virgin Islands Canada Ireland New Zealand Singapore South Africa United Kingdom United States of America

OR

US Virgin Islands and the Caribbean Islands of: Anguilla, Antigua and Barbuda, Barbados, Dominica, Grenada, Grenadines, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent, Trinidad and Tobago.

Section 9 – ANY OTHER INFORMATION THAT YOU WISH TO PROVIDE

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Section 10 – QUESTIONS RELATING TO ELIGIIBLITY TO BE GRANTED A LICENCE Please provide an answer to each of the following questions. If the answer to any of questions 1 through 22 is “yes”, provide an explanation for that answer. Yes No 1. Have you ever had any application for medical licensure rejected?

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Yes No 2. Have ever had your medical license, registration or certificate suspended or revoked?

3. Have you ever been suspended, disqualified, censured, or had any disciplinary action taken against you as a member of any profession?

4. Have you at any time been suspended, expelled or otherwise disciplined for any academic or non-academic offence by a post-secondary institution?

5. Have you at any time during your postgraduate training (internship, residency or fellowship) been suspended, expelled or otherwise disciplined by the post-graduate training program?

6. Have you at any time begun a training program of any description that you did not complete?

7. Have you ever been convicted of a criminal offence?

8. Have you been arrested or charged with any criminal offence, in Canada or elsewhere?

9. To the best of your current knowledge and belief, are you currently under investigation for possible criminal conduct, in Canada or elsewhere?

10. Have you ever been the subject of an enquiry or investigation by a medical licensing authority or hospital?

11. Are you aware of any complaint or charge pending against you by any medical licensing authority which might result in you being suspended, reprimanded or otherwise disciplined?

12. Have you ever had the scope of your medical practice restricted by a medical licensing authority or hospital?

13. Have you ever had your right to bill restricted or removed by a health care paying agency?

14. Have you ever had your privileges restricted, suspended or removed by a hospital or authority controlling a hospital?

15. Have you ever had your staff appointment terminated by a hospital or authority controlling a hospital?

16. Have you ever had your ability to purchase or prescribe narcotic or restricted drugs restricted?

17. Have you ever suffered from any condition that may limit your ability to practice or constitute a risk to patients?

18. Have you been diagnosed or been treated for dependency on or addiction to alcohol or a drug?

19. Have you ever been sued for malpractice?

20. Have you been sued in a civil action relating to fraud?

21. Since obtaining your medical degree, have you ever used a name other than the name under which you are applying for licensure?

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Yes No 22. Have you ever failed any examination or assessment process relating to your

knowledge or skills in medicine or which was intended to lead to certification in the practice of medicine? (Examples of such examinations are the examinations of the Medical Council of Canada, the Royal College of Physicians and Surgeons of Canada, USMLE, FLEX, Royal College of Physicians and Surgeons, American Boards of Medical Specialties, etc.).

If the answer to any of the previous questions is “yes” provide a complete description of the circumstances that relate to the situation that resulted in the answer “yes”.

_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 23. List all licensing authorities that have given you a license or permit to practice medicine starting with the

most recent license held and indicate the exact period of time for which you held each license or permit:

Licensing Authority License Type Start Date End Date

___________________________________ ______________ ______________ _____________ ___________________________________ ______________ ______________ _____________ ___________________________________ ______________ ______________ _____________ ___________________________________ ______________ ______________ _____________ ___________________________________ ______________ ______________ _____________ ___________________________________ ______________ ______________ _____________ ___________________________________ ______________ ______________ _____________

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College of Physicians and Surgeons

500, 321A 21st Street East, SASKATOON SK S7K 0C1 Phone: (306) 244-7355 Fax: (306) 244-0090

Credit Card Charge Form

Date: Physician Name (Please Print): I, authorize the College of Physicians and Surgeons

(Please Print Name) of Saskatchewan to charge my credit card for the amount stated below. Cardholder Name: Address Receipt to be sent to: Postal Code: Amount Authorized: $ Please check one:

Visa Mastercard

Credit Card Number

Expiration Date

FFOORR SSTTAAFFFF UUSSEE OONNLLYY

Date Received: Date Processed:

Amount Charged: Credit Card Type: � Visa � Mastercard

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