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Faculty/Staff
Distributed Campus Clinical Placement Application
McMaster PGME Programs: Please complete the following form to request a core or elective rotation within the Mac-CARE campus regions.
Visiting PGME trainees: Please complete the below form to request an elective placement in the distributed regional sites.
Name
*
First
Last
Date of Birth
*
Citizenship
*
Gender
Male
Female
Other
Residency School
*
Select
McMaster University
Other
List Residency School
*
Residency Program/Training Program
*
Homeschool Program Administrator name:
*
Homeschool Program Administrator email:
*
Student ID Number
*
CPSO #
*
CMPA #
*
MINC #
Level of Learner at time of Elective
*
PGY1
PGY2
PGY3
PGY4
PGY5
PGY6
PGY7
Clinical Fellow
Please note the program
Funding Source
*
(e.g. Ministry of Health & Long Term Care funded (MOHLTC), Department of National Defense (DND) or Foreign-Funded)
Learner Address line 1
*
Learner Address line 2
Email
*
Phone
*
Rotation Information
Rotation Specialty
*
choose one
Allergy/Clinical Immunology
Anatomy
Anesthesia
Cardiac Surgery
Cardiology
Care of the Elderly
Communicable Disease
Community Medicine/Public Health and Preventative Medicine
Critical Care (ICU)
Dermatology
Developmental Pediatrics
Diagnostic Radiology
Emergency Medicine
Endocrinology
ENT
Family Medicine
Family Medicine - Emergency Medicine
Family Medicine - Rural
Gastroenterology
Geriatrics
Hematology
Immunology
Infectious Disease
Intensive Care
Internal Medicine
Internal Medicine - Hospitalist
Laboratory Medicine
Maternal Fetal Medicine
Medical Oncology
Neonatology
Nephrology
Neurology
Neurosurgery
Obstetrics and Gynecology
Oncology
Ophthalmology
Orthopedic Surgery
Otolaryncology Head and Neck
Palliative Care
Pathology
Pediatrics
Physical Medicine and Rehabilitation
Plastic Surgery
Psychiatry
Radiation Oncology
Respirology
Rheumatology
Surgery
Thorasic Surgery
Urology
Vascular Surgery
Core
Elective
Selective
Rotation Start Date
*
*PLEASE NOTE, APPLICATIONS MUST BE SUBMITTED 8 WEEKS IN ADVANCE OF START TO BE CONSIDERED*
Rotation End Date
*
Was the rotation prearranged?
Yes
No
If the rotation was prearranged, by who?
*
Preceptor Name and Location (List all that apply)
Preceptor Email
Additional Rotation Specialty (ie. Selective added to core request)
Vacation approved during rotation
*
Yes
No
If yes, what is the start and end date?
Name of person submitting form
*
Email of person submitting form
*
Date submitted
*
Rotation Site Preference
View Site Map
First Choice
*
Burlington Clinical Education Campus
Grand Erie Six Nations Clinical Education Campus
Halton Clinical Education Campus
Niagara Regional Campus
Waterloo Regional Campus
Osler Clinical Education Campus
Second Choice
*
Burlington Clinical Education Campus
Grand Erie Six Nations Clinical Education Campus
Halton Clinical Education Campus
Niagara Regional Campus
Waterloo Regional Campus
Osler Clinical Education Campus
Third Choice
*
Burlington Clinical Education Campus
Grand Erie Six Nations Clinical Education Campus
Halton Clinical Education Campus
Niagara Regional Campus
Waterloo Regional Campus
Osler Clinical Education Campus
The below sections are only to be completed by non-McMaster Residents
Medical School
Degree Granted
Year Granted
Language of Instruction at Medical School
Have you ever withdrawn or been required to withdraw from any postgraduate medical training?
*
Yes
No
If yes, please explain:
*
Have you ever been disciplined by a university or medical authority?
*
Yes
No
If yes, please explain:
*
Have you ever had your medical license suspended or revoked in any jurisdiction?
*
Yes
No
If yes, please explain:
*
Additional documents will be required with confirmation of elective. These include:
Proof of Current Immunizations
Please complete the PG McMaster Health Screening Record 8 weeks prior to your start date.
View Health Screening page
This does not apply to current McMaster PGME Learners.
Proof of current mask fit test
Letter of good standing and support from your home school program director
CPSO application to be submitted directly to CPSO (at least 8-10 weeks prior to elective start date).
Comments:
Email
Submit
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