practice eligibility route to certification for subspecialists (per … · 2020-02-09 · practice...

Practice Eligibility Route to Certification

for Subspecialists (PER-sub)

FORENSIC PATHOLOGY

Application for Practice Eligibility Route to Certification for Subspecialists (PER-sub)

Candidates pursuing this route to the subspecialty examination must meet the eligibility criteria & belong

to one of the two cohorts.

Eligibility Criteria

a. Royal College certification in a primary specialty that is the entry route to the subspecialty

b. Proof of a valid, unrestricted license to practice in Canada

c. A scope of practice that meets the criteria set out by and acceptable to the discipline’s specialty

committee

d. Attestation by 2 referees of the physician’s scope and quality of his/her practice

e. Registration in the Royal College Maintenance of Certification Program (MOC)

Cohort 1

a. At the time of applying applicants must be in practice for a minimum of 5 years in Canada in the

subspecialty

The last two years of practice must have been in a continuous practice location in Canada

Cohort 2

a. At the time of applying applicants must be in practice for a minimum of 1 year and a maximum of 5

years in Canada in the subspecialty

A minimum of one year must be in a continuous practice location

b. Confirmation of successful completion of training that is equivalent in length to the requirements set

out in the subspecialty’s Specialty Training Requirements. Training must be:

Registered with a Canadian university postgraduate medical education office. Any unaccredited

training must be completed within two years after the first accredited residency program of the

subspecialty has been approved by the Accreditation Committee.

OR

ACGME accredited

Contact the Credentials Unit if a leave of absence was taken delaying the end-of-training date.

Practice Eligibility Route to Certification

for Subspecialists (PER-sub)

FORENSIC PATHOLOGY

PLEASE SEND YOUR COMPLETED FORMS TO:

Postal address:

Royal College of Physicians and Surgeons of Canada

Credentials Unit

774 Echo Drive

Ottawa, ON

K1S 5N8

Email: [email protected]

Fax: 613-730-3707

PLEASE ATTACH THE FOLLOWING DOCUMENTS TO YOUR APPLICATION:

Copy of your CV

Proof of licensure in a Canadian province

Proof of training in the subspecialty as well as details of the training rotations

(for those applying through cohort 2)

IMPORTANT INFORMATION:

The deadline to submit your application for certification via the Practice Eligibilty Route for

Subspecialists is August 31st of the year before you wish to be examined.

Click here for a list of current assessment fees

Should you submit your application after the deadline, you will be subject to a non-refundable

late penalty fee

Please ensure that you have reviewed the criteria before submitting your application

http://www.royalcollege.ca/rcsite/credentials-exams/exam-eligibility/assessment-route/traditional/credentialing-fees-e

http://www.royalcollege.ca/rcsite/credentials-exams/exam-eligibility/assessment-route/traditional/credentialing-fees-e

of 1

Route: Practice Eligibility Route to Certification for

Subspecialists (PER-sub)

Form A: PERSONAL DETAILS

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 email □ Business email

□ Home email □ Business email

IMPORTANT NOTES

You will receive email confirmation that your application has been received.

The Royal College will remain in contact with you via email. Please ensure that we have your

current email 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.

CONTACT INFORMATION

Web: www.royalcollege.ca Mail: 774 Echo Drive

Phone: 1-800-267-2320 Ottawa, ON

Fax: 613-730-3707 K1S 5N8

Email: [email protected]

http://rcpsc.medical.org/residency/certification/per_e.php

mailto:[email protected]

of 1



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: ______________________________

of 1



Form C: DECLARATION

Form B: 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 __________

PER-sub: Application FORENSIC PATHOLOGY

Page 1 of 9

Route: Practice Eligibility Route to Certification for Subspecialists (PER-sub)

Form D: SCOPE OF PRACTICE – Forensic Pathology

Royal College use only: Royal College ID:

Identification:

Surname:

Given name:

Type of Medico-legal Death Investigation System Currently Employed: Yes No

Medical Examiner’s System

Coroner’s System

Do you act as a Medical Examiner or Coroner?

Do you complete death certificates or have access to them?

Current Practice Setting (indicate all which apply): Yes No

Centralized Provincial Forensic Pathology Unit

Regional Forensic Pathology Unit

Teaching Hospital

Community Hospital

Other (Specify) :

Facility Overview:

Does the facility have access to? Yes No

Digital Photography

Medical Imaging

Ancillary Laboratories

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.


Page 2 of 9



1. Current Staffing # of Staff

Pathologists doing Medico-legal Autopsies including Homicides =

Pathologists doing Medico-legal Autopsies excluding Homicides =

Pathology Assistants (PAs), Autopsy Assistants, Autopsy Technicians or equivalent =

Briefly describe the role of a PA or equivalent during an autopsy in your current Practice setting:

2. Forensic Pathology Load

a) If the number of autopsies is less than the suggested guideline (150 cases/year of fulltime practice; 75 cases/year if 50% practice), please provide an explanation:


Page 3 of 9



b) Please provide your case numbers for the calendar year January 1, to December 31, 2011:

I. Complete Post mortem Examinations:

PEDIATRIC (< 5YRS OLD) # of Cases

SIDS / SUDS

Natural (Disease)

Accidents

Homicide / Criminally suspicious

ALL OTHER AGES # of Cases

Natural

Accident / Suicide

Homicide / Criminally suspicious

Underdetermined

II. External Examinations only:

# of Cases

Natural

Accident / Suicide

c) If your current practice does not include pediatric cases, please explain. Outline any previous pediatric forensic pathology experience.


Page 4 of 9



d) # Scenes Attended or Assessed using Photographic Images =

e) Does the Practice Setting have an organ retention policy? □ Yes □ No

Briefly describe below (or append relevant document) :

f) Does your Practice Setting or jurisdiction have a policy regarding tissue/organ procurement in medico-legal cases?

□ Yes □ No

Briefly describe below (or append relevant document) :

3. Access to and Use of Expertise Yes No

Neuropathology

Cardiovascular Pathology

Others (e.g. other pathologists)

Radiology Referrals

Forensic Odontology Referrals

Anthropology Referrals


Page 5 of 9



4. Other Service Commitments

If not in full-time forensic pathology practice, briefly outline other professional duties (if applicable) and their time allocation.

5. Administration

Outline any administrative role(s) you have in your current practice setting (e.g. Committees, advisory bodies, etc.) particularly as it (they) relate(s) to Forensic Pathology.

6. Consultation and Testimony

If you do not provide or have not provided medico-legal consultation/testimony in your current practice, please explain. Outline any past experience.

a) Consultations (excluding cases requiring your testimony in a legal proceeding) from January 1, to December 31, 2011:

# of Cases

Criminal

Civil

Other (please specify) :


Page 6 of 9



b) Testimony by Applicant from January 1, to December 31, 2011: # of cases

Inquest / Inquiries

Preliminary Hearings

Trials (specify# of cases acting for the defence)

- Criminal

- Civil

- Other (please specify) :

7. Case Management

a) Are interdisciplinary case conferences involving members of the medico-legal death investigation team held prior to release of the report to discuss issues of mutual concern?

□ Yes □ No

What has been your general role in these case conferences?

b) Are the majority of your cases signed out within 6 months? □ Yes □ No

c) Turn Around Time (TAT) for homicides and criminally suspicious cases =

d) List barriers to TAT (if applicable) :


Page 7 of 9



e) Is there a peer review process of autopsy reports? □ Yes □ No

Briefly outline the process (if applicable) :

f) Following the release of your report, do you meet with lawyers prior to any legal proceedings (preliminary hearing, trial, inquest, other)? □ Yes □ No

8. Teaching

a) Do you participate in Departmental Rounds? (list below) □ Yes □ No

b) Do you have a university academic appointment? (specify below) □ Yes □ No

c) Briefly describe your role as a teacher of forensic pathology during the specified duration of practice (reference can be made to an attached CV). What percentage of your time is spent teaching?


Page 8 of 9



9. Research

Briefly describe, if applicable, any research (studies, presentations, publications) you have undertaken related to forensic pathology during the specified duration of practice (reference can be made to an attached CV) :

10. Continuing Medical Education

a) Does your current practice facility have access to? Yes No

Internet Access

Current Forensic Pathology Textbooks

Forensic Journals

University Library

b) Do you participate in continuing education programs? □ Yes □ No

List programs in last 12 months :

c) Do you participate in online educational programs? □ Yes □ No

List programs in last 12 months :


Page 9 of 9



d) Do you participate in external quality control programs (e.g. ASCP)? □ Yes □ No

e) Do you attend provincial, national or international meetings which have Forensic Pathology content? □ Yes □ No

List those attended in 2011-2012 or in the last 2, 3, or 6 years dependent upon your training/practice profile as outlined on page 1 of this questionnaire:

f) Briefly describe, using a specific case example, how an evidence-based* approach assisted in the resolution of a controversial issue and/or affected your practice.

* Evidence-based approach definitions:

1. the Forensic Pathologist has an open mind to a number of possibilities at the beginning of a case, and by integration of objective evidence from the autopsy and other information reaches a conclusion, and

2. the Forensic Pathologist’s practice integrates individual expertise with the best available knowledge from research in the discipline

PER-sub: Multi-source Feedback (MSF)

Child and Adolescent Psychiatry (CAP)

1 of 2



Form E: REFEREE VERIFICATION (RV) – Forensic

Pathology

Applicant Identification:

Surname:

Given name:

A: Identification of Referee #1 – Non Medical Co-Worker

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

E-mail

B: Identification of Referee #2 – Medical Colleague


Name:


Street no. and name

Apt no.

City

Province

Country

Postal Code

ext.( )

Telephone

Fax

E-mail

Please provide the names of individuals who have knowledge of your professional practice in each of

the categories listed below. They will be contacted and asked to provide feedback on your practice.

A release of information form for each of your referees must be appended to this form

(see Form F).



2 of 2



Form E: REFEREE VERIFICATION (RV) – Forensic

Pathology

C: Identification of Referee #3 – Attorney


Name:


Street no. and name

Apt no.

City

Province

Country

Postal Code

ext.( )

Telephone

Fax

E-mail

D: Identification of Referee #4 – Member of the Death Investigation Team


Name:


Street no. and name

Apt no.

City

Province

Country

Postal Code

ext.( )

Telephone

Fax

E-mail



1 of 1



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

of 1


Subspecialists (PER-Sub)

Form G: 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)

Practice Eligibility Route to Certification for Subspecialists (PER-sub)

CURRICULUM VITAE (CV) – Cover Page

*Please attach your Curriculum Vitae (CV) behind this cover page


Provincial License – Cover Page

*Please attach a copy of your license to practice behind this cover page


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

practice eligibility route to certification for subspecialists (per … · 2020-02-09 · practice...

Documents