FM - Non Physician Application Form

Fields denoted by an asterisk (*) are required.

Personal Information
Name Name First Last
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Practice Address Practice Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Contact Information
Contact Information Office Phone Contact Information Office Phone - ### - ### ####
Contact Information Office Fax Contact Information Office Fax - ### - ### ####
Contact Information Office Alternate Phone Contact Information Office Alternate Phone - ### - ### ####
Email Address

The preferred method of contact will be your Western email address which you will receive once your application is complete.
Do you have a Western/Student ID number?

Do you have a Western/Student ID number? Yes No
Western/Student ID#
Profession
Profession

Profession Social Worker Nurse Nurse Practitioner Dietician Pharmacist Psychologist Occupational Therapist Other Other
Education Information
Degree(s)

Degree(s) Masters PhD Other Other
Please list name of School(s) you received your degree(s) from:
Why are you interested in teaching?

Why are you interested in teaching? Personal Satisfaction Academic Affiliation Community Exposure Recruitment Other Other
If applicable, please expand on your selection.
Have you participated in teaching before?

Have you participated in teaching before? Yes No
Previous experience to benefit this position. Please check all that apply:

Previous experience to benefit this position. Please check all that apply: Large Classroom Teaching Small Group Teaching Clinical Supervisor of Undergraduate Students Clinical Supervisor of Postgraduate Residents Research supervisor of Undergraduate Students Research supervisor of Postgraduate Residents Examiner (e.g., OSCE, CCFP, RCPSC) Curriculum Development Accreditation Education Administration (e.g. participation in Committee) Administrative Role (e.g. Academic Director) Peer Reviewed Publications Publications of guidelines/policies Teaching Awards Attended Faculty Development Workshops to augment academic skills relating to teaching, leadership, management, etc Other Other
If applicable, please expand on your selection
Please indicate the College or Regulatory body you are affiliated with:
Are you a member in good standing with the above College or regulatory body?

Are you a member in good standing with the above College or regulatory body? Yes No
You have indicated you are not a member in good standing with the College or regulatory body you are affiliated with, please explain:
Are you legally entitled to work in Canada?

Are you legally entitled to work in Canada? Yes No
Please explain why you are not legally entitle to work in Canada:
Have you been disciplined by a professional licensing body?

Have you been disciplined by a professional licensing body? Yes No
You have indicated you have been disciplined by a professional licensing body, please explain:
Have there been any decisions made against you by a professional licensing body?

Have there been any decisions made against you by a professional licensing body? Yes No
Please explain the decission made against you:
Have you entered into an agreement with, made a promise to, or given an undertaking to a professional licensing body in the face of a potential disciplinary action by the body?

Have you entered into an agreement with, made a promise to, or given an undertaking to a professional licensing body in the face of a potential disciplinary action by the body? Yes No
Please explain the agreement made:
Have you been found guilty of a criminal offense in Canada or elsewhere?

Have you been found guilty of a criminal offense in Canada or elsewhere? Yes No
Please explain the guilty finding:
Practice Information
Practice Name
Are you part of a:

Are you part of a: CHC FHN FHO FHT Group Practice Sole Practice Hopsital Private Practice
Please identify which CHC you belong to:
Please identify which FHT you belong to:
What other staff do you work with?

What other staff do you work with? Not Applicable Nurse Practitioner Physiotherapist Occupational Therapist Physician Assistant Registered Dietician Social Worker Registered Nurse Dentist Lab Technician Physician Other Other
If applicable, please expand on your selection.
Resources available to learners in your office include:

Resources available to learners in your office include: Computer CD-ROM Internet Research Medical Journals Textbooks UpToDate Other Other
If applicable, please expand on your selection.
PRACTICE DESCRIPTION
Description of Practice
Description of Community
Affiliated Hospital
Educational Supports
How can the Schulich School of Medicine & Dentistry enhance your experience as a faculty member?
Are there any obstacles that you have encountered as a faculty member?
Are you interested in pursuing any of the following?

Are you interested in pursuing any of the following? Research Leadership Development Continuing Medical Education Leadership Roles Faculty Development
Please define in what way you would like to receive faculty development. Check all that apply:

Please define in what way you would like to receive faculty development. Check all that apply: Lecture or workshop in your community Lecture or workshop on campus (London or Windsor) Independent learning resources (audio, video, CD-ROM, reading) Conference (attend in person) Conference call (audio, video) Distance Learning (Internet based) Small Group Discussion Self-Learning Project Mentorship (Coaching) Virtual group with peers interested in similar topics Peer Dialogue(Is a joint project between Continuing Professional Development, Undergraduate Medical Education and Postgraduate Medical Education. Peer Dialogue is a process by which feedback in teaching is provided by one's peers in order to build a cadre of excellent teachers across the continuum of education.)
References

Please provide "Practice" contact information for address fields.
Reference One Name Reference One Name First Last
City
Reference One Phone Reference One Phone - ### - ### ####
Reference One Fax Reference One Fax - ### - ### ####
Reference One Email Address
Reference Two Name Reference Two Name First Last
City
Reference Two Phone Reference Two Phone - ### - ### ####
Reference Two Fax Reference Two Fax - ### - ### ####
Reference Two Email Address
Reference Three Name Reference Three Name First Last
City
Reference Three Phone Reference Three Phone - ### - ### ####
Reference Three Fax Reference Three Fax - ### - ### ####
Reference Three Email Address
TEACHING INTERESTS

The department of Family Medicine has a variety of opportunities for you to be involved in the teaching of undergraduate students and postgraduate residents. We would appreciate your feedback as to what type of teaching you are interested in. Please indicate the teaching opportunities you may be interested in.
Undergraduate Teaching
1st and 2nd Year Medical

1st and 2nd Year Medical Electives - In practice, length of time varied Clinical Methods - Patient-Centred Interviewing (Yr 1) On campus, one afternoon a wk for 8 wks (Sep-Oct) Longitudinal Clinical Experience - In practice, 8-16 half days (Sep-May) PCCIA Small Groups (Patient-Centred Context - Integration & Application) Wkly small group series for 12 wks (fall & winter) Lectures - On campus, lenght of time varied
3rd Year Medical Students

3rd Year Medical Students Clinical Clerkship - In practices, 4 wks (yr round)
4th Year Medical Students

4th Year Medical Students Western Student Electives - In practice, 2-4 wks (Sep-Dec) Visiting Student Elevtives - In pracitce, 2-4 wks (yr round)
Total Number of Undergraduate Students per Year?
Months NOT available
Comments
Postgraduate Teaching
PGY1 or PGY2 Residents

PGY1 or PGY2 Residents Rural FM rotation - in practice 8 wks Elective rotation - in practice 4 or 8 wks
Rural - No. of residents/yr that can be accommodated
Rural - Months NOT available
Elective - No. of residents/yr that can be accommodated
Elective - Months NOT available
International Medical Graduate (IMG) Pre-Residency Program Teaching

Introduction to primary care for IMG's prior to starting their FM residency. They are expected to function at a clinical clerk level. No assessment is required.
IMG's

IMG's Spring Program (Residency starts in July) - 2wks in May-June
No. of residents/yr that can be accommodated
Months NOT available
If you wish to discuss these options in more detail, please contact:

Undergraduate Teaching: Michele Vanderspank fmundergrad@schulich.uwo.ca
Postgraduate Teaching: fmpgc@schulich.uwo.ca
IMG Pre-Residency Program: Cheryl Lystra-Lantz fmpgc@schulich.uwo.ca
Windsor Program: Linda Di Rosa linda.dirosa@uwindsor.ca
Please attach a copy of your current CV * Uploaded file type must be: doc, docx, pdf or txt. The maximum acceptable file size is 20MB.

Attach Files

Uploaded file type must be: doc, docx, pdf or txt. The maximum acceptable file size is 20MB.
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Western respects your privacy. The personal information collected on this form is collected under the authority of The University of Western Ontario Act, 1992, as amended, and is used for the purpose of consideration for an academic appointment for preceptor activities. Please direct questions about this collection, use, or disclosure of personal information to Associate Director, Human Resources, Schulich School of Medicine & Dentistry, 519-661-3459.

If you experience technical problems with this form, please contact the helpdesk 519-661-2111 x81377; Hours Monday to Friday 8:00-4:30

FM - Non Physician Application Form

FM - Non Physician Application Form

Personal Information

Contact Information

Profession

Education Information

Practice Information

PRACTICE DESCRIPTION

Educational Supports

References

TEACHING INTERESTS

Undergraduate Teaching

Postgraduate Teaching

International Medical Graduate (IMG) Pre-Residency Program Teaching

If you wish to discuss these options in more detail, please contact: