Skip to McMaster Navigation Skip to Site Navigation Skip to main content

FACULTY OF HEALTH SCIENCES

Postgraduate Medical Education

Search button Menu button

Home
Discover
Apply
Register
Train
Succeed
Who to Contact
Faculty/Staff Hub

Distributed Campus Clinical Placement Application

McMaster PGME Trainees & Visiting PGME Trainees:
Please complete the following form to request a core or elective rotation within the Mac-CARE campus regions.

(Burlington, Grand Erie Six Nations, Halton, Niagara, Osler, & Waterloo)

Name *

First

Last

Date of Birth *

Citizenship *

Gender

Home Residency School *

Name of Home Residency School *

Homeschool 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 Placement Requested *

Type of Rotation *

Core
Elective
Selective

Requested Rotation Start Date *

*PLEASE NOTE, APPLICATIONS MUST BE SUBMITTED 8 WEEKS IN ADVANCE OF START TO BE CONSIDERED*

Requested Rotation End Date *

Was the rotation prearranged? *

Yes
No

Full name of preceptor who prearranged the rotation *

Preceptor Email *

Location of prearranged rotation *

Burlington Clinical Education Campus - Joseph Brant
Grand Erie Six Nations Clinical Education Campus - Brantford, Paris, Dunnville, Simcoe, Hagersville, Caledonia, Delhi, Oshweken, Port Dover
Halton Clinical Education Campus - Georgetown/Halton Hills, Milton, Oakville
Niagara Regional Campus - Fort Erie, Niagara Falls, Port Colborne, St. Catharines, Welland, Grimsby, Beamsville, Niagara-on-the-Lake, Smithville
Osler Clinical Education Campus - Brampton, Etobicoke, Peel Memorial Centre for Integrated Health & Wellness
Waterloo Regional Campus - Cambridge, Guelph, Fergus, Mount Forest, Palmerston, Kitchener, Drayton, Elmira, Elora, Rockwood, Waterloo, Wellesley
OTHER

OTHER (copy) *

Newmarket
Markham

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 - Joseph Brant
Grand Erie Six Nations Clinical Education Campus - Brantford, Paris, Dunnville, Simcoe, Hagersville, Caledonia, Delhi, Oshweken, Port Dover
Halton Clinical Education Campus - Georgetown/Halton Hills, Milton, Oakville
Niagara Regional Campus - Fort Erie, Niagara Falls, Port Colborne, St. Catharines, Welland, Grimsby, Beamsville, Niagara-on-the-Lake, Smithville
Osler Clinical Education Campus - Brampton, Etobicoke, Peel Memorial Centre for Integrated Health & Wellness
Waterloo Regional Campus - Cambridge, Guelph, Fergus, Mount Forest, Palmerston, Kitchener, Drayton, Elmira, Elora, Rockwood, Waterloo, Wellesley
OTHER

OTHER *

Newmarket
Markham

Second Choice *

Burlington Clinical Education Campus - Joseph Brant
Grand Erie Six Nations Clinical Education Campus - Brantford, Paris, Dunnville, Simcoe, Hagersville, Caledonia, Delhi, Oshweken, Port Dover
Halton Clinical Education Campus - Georgetown/Halton Hills, Milton, Oakville
Niagara Regional Campus - Fort Erie, Niagara Falls, Port Colborne, St. Catharines, Welland, Grimsby, Beamsville, Niagara-on-the-Lake, Smithville
Osler Clinical Education Campus - Brampton, Etobicoke, Peel Memorial Centre for Integrated Health & Wellness
Waterloo Regional Campus - Cambridge, Guelph, Fergus, Mount Forest, Palmerston, Kitchener, Drayton, Elmira, Elora, Rockwood, Waterloo, Wellesley
OTHER

OTHER *

Newmarket
Markham

Third Choice *

Burlington Clinical Education Campus - Joseph Brant
Grand Erie Six Nations Clinical Education Campus - Brantford, Paris, Dunnville, Simcoe, Hagersville, Caledonia, Delhi, Oshweken, Port Dover
Halton Clinical Education Campus - Georgetown/Halton Hills, Milton, Oakville
Niagara Regional Campus - Fort Erie, Niagara Falls, Port Colborne, St. Catharines, Welland, Grimsby, Beamsville, Niagara-on-the-Lake, Smithville
Osler Clinical Education Campus - Brampton, Etobicoke, Peel Memorial Centre for Integrated Health & Wellness
Waterloo Regional Campus - Cambridge, Guelph, Fergus, Mount Forest, Palmerston, Kitchener, Drayton, Elmira, Elora, Rockwood, Waterloo, Wellesley
OTHER

OTHER *

Newmarket
Markham

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 *

Click or drag a file to this area to upload.

Letter of good standing and support from your home school program director

Click or drag a file to this area to upload.

CPSO application to be submitted directly to CPSO (at least 8-10 weeks prior to elective start date).

Comments:

Phone

FACULTY OF HEALTH SCIENCES Postgraduate Medical Education

Twitter Facebook Instagram YouTube

Learner Portals

MedPortal login

PGME News/Event to share?

Submit a news form

1280 Main Street West
Hamilton ON L8S 4L8
MDCL 3101A
(905) 525-9140

Media Production Services is committed to providing websites that are accessible to the widest possible audience.
If there is an AODA web accessibility issue with this website, please report it to us by using our AODA bug reporting form.

This website is powered by MacSites

Contact
Terms & Conditions
Privacy Policy

1280 Main Street West Hamilton, Ontario L8S 4L8
(905) 525-9140

© 2023 McMaster University