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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

Residency School *

List Residency School *

Residency Program/Training Program *

Homeschool Program Administrator name: *

Homeschool Program Administrator email: *

Student ID Number *

CPSO # *

CMPA # *

MINC #

Level of Learner

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 *

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

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Have you ever withdrawn or been required to withdraw from any postgraduate medical training?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

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:

Name

FACULTY OF HEALTH SCIENCES Postgraduate Medical Education

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