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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 *

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

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