New Applicant Form | Medical Tracking

First Name

Last Name

Email Address

Birthday

Month Day Year

Department(s)/Division(s)

EMERGENCY

BGH

TMH

NHH

FAMILY MEDICINE

BGH

TMH

PECM

Rehabilitation

MEDICINE & CRITICAL CARE

DIAGNOSTIC IMAGING

Nuclear Medicine

Radiology

OBSTETRICS & GYNAECOLOGY

Obstetrics & Gynaecology

Midwifery

PAEDIATRICS

LABORATORY MEDICINE

PSYCHIATRY

ANAESTHESIA

BGH

TMH

PART TWO:

Changes requested in procedural privileges

Supporting Documents

PART THREE:

CONTINUING MEDICAL EDUCTIONAL PROGRAMS AND CERTIFICATION UPDATES:

A. Continuing Education

B. Physicians MOCOMP

C: Dentists/Oral Surgeons CE e-Portfolio

D: Midwives Proof of Compliance

E. Nurses CNO

Comments on the above

PART FOUR:

LIABILITY INSURANCE:

PHYSICIANS CMPA Membership Update

DENTISTS RCDSO Membership Certificate

NURSE PRACTITIONERS RNAO Membership Certificate

MIDWIVES Professional Liability Protection

PART FIVE:

Other privileges than Quinte Health Care

Yes

No

If Yes, please complete the section below

Hospital 1

Location 1

Staff Category 1

Extent of Privileges 1

Hospital 2

Location 2

Staff Category 2

Extent of Privileges 2

Hospital 3

Location 3

Staff Category 3

Extent of Privileges 3

Hospital 4

Location 4

Staff Category 4

Extent of Privileges 4

Academic appointments?

PART SIX:

If the answer to any part of the following questions is true, please provide a written statement describing details and append it to this application.

A. Disciplinary actions

Yes

No

If yes, please provide details

B. Investigation failure

Yes

No

If yes, please provide details

C. Civil suit

Yes

No

If yes, please provide details

D. Criminal proceedings

Yes

No

If yes, please provide details

PART SEVEN:

Please provide any changes to your contact information, including email:

Office Address:

Office City

Office Province

Office Postal Code

Office Telephone:

Office Fax:

Home Address:

Home City

Home Province

Home Postal Code

Home Telephone:

Email Address:

PART EIGHT:

I hereby affirm that I have read the Public Hospitals Act, the Hospital Management Regulation thereunder, the Quinte Health Care Professional Staff Bylaws and General Rules & Regulations. I understand that if appointed to the Professional Staff, I will provide the services to the Hospital as stipulated in this application, and will govern myself in accordance with the requirements set out in the Public Hospitals Act, other relevant Acts, the Quinte Health Care Professional Staff Bylaws, General Rules & Regulations and policies. I acknowledge that failure to provide the said services constitutes a breach of my duties, and that the Hospital may, upon consideration of the individual circumstances, remove my access to any and all Hospital resources, including the limiting or restricting of operating room time, or take such action as is reasonable, in accordance with the Professional Staff Bylaws and General Rules & Regulations. I acknowledge that the Hospital may refuse to appoint me to the Professional Staff if I refuse to acknowledge the responsibility to abide by a commitment to provide services in accordance with the Privileges granted by the Board, and in accordance with the Quinte Health Care Professional Staff Bylaws, General Rules & Regulations and policies.

I agree

Yes

Attach Previous Procedural Privileges

not used

Describe the scope of your practice

Hospital5

Location5

StaffCategory5

Privileges5

Hospital6

Location6

StaffCategory6

Privileges6

Hospital7

Location7

StaffCategory7

Privileges7

Hospital8

Location8

StaffCategory8

Privileges8

Cellular Phone

Vacation Residence Phone

Department Division Change Request

Other Project

Continuing Education 1

Continuing Education 2

Continuing Education 3

Continuing Education 4

Continuing Education 5

Continuing Education 6

Liability Insurance 1

Liability Insurance 2

Office Use Only 1

Office Use Only 2

Office Use Only3

Office Use Only 4

Billing Number

projects you would consider assisting in

***** NEW APPLICANT FIELDS BELOW *****

Background

Curriculum Vitae

Please attach your curriculum vitae

Licensed to practice in Ontario*

Yes

No

CPSO Number

Other membership type and number

Royal College of Dental Surgeons of Ontario

College of Nurses of Ontario

Date of License

Medicine or Nursing or Midwifery

Degree

University, Medical, or Nursing School

City and country of University, Medical, or Nursing School

Degree Year

Postgraduate qualifications

Qualification1

Specialty1

University or College1

Year1

Qualification2

Specialty2

University or College2

Year2

Qualification3

Specialty3

University or College3

Year3

Qualification4

Specialty4

University or College4

Year4

Qualification5

Specialty5

University or College5

Year5

Qualification6

Specialty6

University or College6

Year6

ATLS

Year ATLS obtained

ACLS

Year ACLS obtained

PALS

Year PALS obtained

ALARM

Year ALARM obtained

NRP

Year NRP obtained

Other - Specify

Graduate medical training (internships, residencies, etc.): (please list in chronological order)

Date1

Appointment1

Institution1

Location1

Date2

Appointment2

Institution2

Location2

Date3

Appointment3

Institution3

Location3

Date4

Appointment4

Institution4

Location4

Date5

Appointment5

Institution5

Location5

Have you participated regularly in recognized programs for continuing medical education or self-evaluation?

Yes

No

Please give particulars:

MAINPRO or MOCOMP

Eligibility to sit certification examinations:

College of Family Physicians of Canada:

Yes

No

Completed

Date completed or date expected

Royal College of Physicians and Surgeons of Canada:

Yes

No

Completed

Date completed or date expected

EXPERIENCE:

Teaching appointments:

Professional practice:

Yes

No

Practice Date1

Practice Facility 1

Practice Location 1

Practice Type 1

Practice Date 2

Practice Facility 2

Practice Location 2

Practice Type 2

Practice date 3

Practice Facility 3

Practice Location 3

Practice Type 3

Practice Date 4

Practice Facility 4

Practice Location 4

Practice Type 4

Practice Date 5

Practice Facility 5

Practice Location 5

Practice Type 5

Hospital staff memberships (past and present):

Staff Date 1

Staff Privs 1

Staff Date 2

Staff Privs 2

Staff Date 3

Staff Privs 3

Staff Date 4

Staff Privs 4

Staff Date 5

Staff Privs 5

HOSPITAL PRIVILEGES AND LEGAL ACTIONS:

Have you ever been denied the hospital privileges for which you have applied?

Yes

No

Have your hospital privileges ever been reduced, suspended or revoked for any reason?

Yes

No

Have you ever voluntarily relinquished part or all of your hospital privileges?

Yes

No

Have you ever been the subject of an adverse finding by the Discipline Committee of the College of Physicians and Surgeons of Ontario (or as appropriate the Discipline Committee of the College of Dental Surgeons of Ontario, or College of Nurses of Ontario, or the College of Midwives of Ontario)?

Yes

No

Have you ever been the subject of an adverse finding by a Discipline Committee of other than Ontario?

INSURANCE COVERAGE:

ELIGIBILITY TO WORK IN CANADA:

Are you legally authorized to work in Canada for QHC in the role being applied for?

Yes

No

Please attach a copy of the following:

ROLE DESCRIPTION AND PRIVILEGES

Specialty

Please describe the role you intend to have at Quinte Health Care

References

Professional (please provide complete details for three references):

Name 1

Street 1

City 1

Province 1

Country 1

Postal Code 1

Phone 1

Fax 1

Email 1

Name 2

Street 2

City 2

Province 2

Country 2

Postal Code 2

Phone 2

Fax 2

Email 2

Name 3

Street 3

City 3

Province 3

Country 3

Postal Code 3

Phone 3

Fax 3

Email 3

Hospital (names and complete details for where last appointments held):

Chief of Medical Staff (last appointment)

Name

Street

City

Province

Country

Postal Code

Phone

Fax

Email

Chief of Department (last appointment)

Name

Street

City

Province

Country

Postal Code

Phone

Fax

Email

Teaching appointments:

Date

Appointment

Institution

Date

Appointment

Institution

Date

Appointment

Institution

Date

Appointment

Institution

College of Midwives of Ontario

Currently outside Canada

References

Please provide the names, roles, and complete contact details of at least three references, including for physicians the Chief of Staff or Program Director of your last appointment and the Chief of Department for your last appointment

Reference Name 1

Reference Name 2

Reference Name 3

Reference Name 4

Reference Name 5

Reference Address 1

Reference Address 2

Reference Address 3

Reference Address 4

Reference Address 5

Reference Phone 1

Reference Phone 2

Reference Phone 3

Reference Phone 4

Reference Phone 5

Reference Email 1

Reference Email 2

Reference Email 3

Reference Email 5

Good Standing

I confirm I have or will request my proof of good standing.