Clinical Faculty (MD) Reapplication Form

Fields denoted by an asterisk (*) are required.

Personal Information
Name Name First Last
Primary Email
Primary Phone Primary Phone - ### - ### ####
Practice Information
Practice Name
Practice Address Practice Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Practice Phone Practice Phone - ### - ### ####
Practice Fax Practice Fax - ### - ### ####
Practice Email Address
Do you have a Medical Professional Corporation?

Do you have a Medical Professional Corporation? Yes No
Corporation Name
Incorporated Business Number
HST

HST Yes No
HST Number
Is your Incorporated address the same as your practice address above?

Is your Incorporated address the same as your practice address above? Yes No
Incorporation Business Address Incorporation Business Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Information
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Western Information
Primary Department
Please select the department you are appointed in:
Primary Rank
Activity Summary

Please check all activities conducted during the term of your previous appointment. Also, indicate which activities gave you the most satisfaction.
	Conducted	Most Satisfaction
Large Class Teaching	Large Class TeachingConducted	Large Class TeachingMost Satisfaction
Small Group Teaching	Small Group TeachingConducted	Small Group TeachingMost Satisfaction
Clinical Supervisor of Undergraduate Students	Clinical Supervisor of Undergraduate StudentsConducted	Clinical Supervisor of Undergraduate StudentsMost Satisfaction
Clinical Supervisor of Postgraduate Residents	Clinical Supervisor of Postgraduate ResidentsConducted	Clinical Supervisor of Postgraduate ResidentsMost Satisfaction
Research supervisor of Undergraduate Students	Research supervisor of Undergraduate StudentsConducted	Research supervisor of Undergraduate StudentsMost Satisfaction
Research supervisor of Postgraduate Residents	Research supervisor of Postgraduate ResidentsConducted	Research supervisor of Postgraduate ResidentsMost Satisfaction
Examiner (e.g., OSCE, CCFP, RCPSC)	Examiner (e.g., OSCE, CCFP, RCPSC)Conducted	Examiner (e.g., OSCE, CCFP, RCPSC)Most Satisfaction
Curriculum Development	Curriculum DevelopmentConducted	Curriculum DevelopmentMost Satisfaction
Accreditation	AccreditationConducted	AccreditationMost Satisfaction
Education Administration (e.g. participation in Committee)	Education Administration (e.g. participation in Committee)Conducted	Education Administration (e.g. participation in Committee)Most Satisfaction
Administrative Role (e.g. Academic Director, Course Coordinator)	Administrative Role (e.g. Academic Director, Course Coordinator)Conducted	Administrative Role (e.g. Academic Director, Course Coordinator)Most Satisfaction
Peer Review Publications	Peer Review PublicationsConducted	Peer Review PublicationsMost Satisfaction
Publications of guidelines/policies	Publications of guidelines/policiesConducted	Publications of guidelines/policiesMost Satisfaction
Attended Faculty Development Workshops to augment academic skills relating to teaching, leadership, management, etc.	Attended Faculty Development Workshops to augment academic skills relating to teaching, leadership, management, etc.Conducted	Attended Faculty Development Workshops to augment academic skills relating to teaching, leadership, management, etc.Most Satisfaction
Classroom Teaching	Classroom TeachingConducted	Classroom TeachingMost Satisfaction
Having medical learners in my practice	Having medical learners in my practiceConducted	Having medical learners in my practiceMost Satisfaction
Bedside teaching in the CTU	Bedside teaching in the CTUConducted	Bedside teaching in the CTUMost Satisfaction
Developing my teaching skills	Developing my teaching skillsConducted	Developing my teaching skillsMost Satisfaction
Coaching medical learners	Coaching medical learnersConducted	Coaching medical learnersMost Satisfaction
Mentoring medical learners	Mentoring medical learnersConducted	Mentoring medical learnersMost Satisfaction
Conducting independent research	Conducting independent researchConducted	Conducting independent researchMost Satisfaction
Quality Improvement project facilitation	Quality Improvement project facilitationConducted	Quality Improvement project facilitationMost Satisfaction
Annual Skills Day	Annual Skills DayConducted	Annual Skills DayMost Satisfaction
Portfolio	PortfolioConducted	PortfolioMost Satisfaction
Clerkship involvement	Clerkship involvementConducted	Clerkship involvementMost Satisfaction
Clinical Science/Summer Electives	Clinical Science/Summer ElectivesConducted	Clinical Science/Summer ElectivesMost Satisfaction
Simulation	SimulationConducted	SimulationMost Satisfaction
Evaluations	EvaluationsConducted	EvaluationsMost Satisfaction
Teaching UME	Teaching UMEConducted	Teaching UMEMost Satisfaction
Teaching PGME	Teaching PGMEConducted	Teaching PGMEMost Satisfaction
Continuing Medical Education for Peers	Continuing Medical Education for PeersConducted	Continuing Medical Education for PeersMost Satisfaction
Continuing Medical Education for Allied Health Professionals	Continuing Medical Education for Allied Health ProfessionalsConducted	Continuing Medical Education for Allied Health ProfessionalsMost Satisfaction

Other Activity, please explain
What teaching, research, leadership and/or other academic scholarly activities do you want to accomplish in the Department during your next Adjunct Professor appointment?
Research Experience and Interest
Are you interested in participating in and/or conducting Research during your next adjunct appointment?
(Discussion with the Chair of the Department is required before a Research appointment is
approved.)

Are you interested in participating in and/or conducting Research during your next adjunct appointment?
(Discussion with the Chair of the Department is required before a Research appointment is
approved.) Yes No
Have you participated in Research before?

Have you participated in Research before? Yes No
Please describe your previous Research experience.
Please describe your Research area of interest.
Please describe your Research training.
Have you completed Mandatory Training for Human Research through the Tri-Council
(TCPS2 CORE) or training through the Collaborative Institutional Training Initiative (CITI)?

Have you completed Mandatory Training for Human Research through the Tri-Council
(TCPS2 CORE) or training through the Collaborative Institutional Training Initiative (CITI)? Yes No
Will access to research funding be required?

Will access to research funding be required? Yes No
Will access to Western Research Ethics Board be required?

Will access to Western Research Ethics Board be required? Yes No
Will medical learners be assisting with your research and require supervision?

Will medical learners be assisting with your research and require supervision? Yes No
License Information
CMPA Number
CMPA Effective Date CMPA Effective Date / MM / DD YYYY
FRCPC, Year Completed
CCFP, Year Completed
RCPSC Specialist, Year Completed
CFPC Specialist, Year Completed
CPSO Number
CPSO Effective Date CPSO Effective Date / MM / DD YYYY
Restricted CPSO License

Restricted CPSO License Yes No
Describe Restriction
Restriction Effective Date Restriction Effective Date / MM / DD YYYY
Restriction Expiry Date Restriction Expiry Date / MM / DD YYYY
Other
Attestations
Are you a Canadian Citizen?

Are you a Canadian Citizen? Yes No
Please attach Permanent Resident/Work Permit Information

Attach Files
Are you legally entitled to work in Canada?

Are you legally entitled to work in Canada? Yes No
Please explain
Are you a member in good standing with the College of Physicians & Surgeons of Ontario (CPSO)?

Are you a member in good standing with the College of Physicians & Surgeons of Ontario (CPSO)? Yes No
Please explain
Have you been disciplined by a professional licensing body?

Have you been disciplined by a professional licensing body? Yes No
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
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
Have you been found guilty of a criminal offense in Canada or elsewhere relevant to your suitability to practice medicine?

Have you been found guilty of a criminal offense in Canada or elsewhere relevant to your suitability to practice medicine? Yes No
Please explain
Hospital Information
Hospital Privileges

Hospital Privileges Yes No
Hospital Name One
Hospital Name Two
Hospital Name Three
Have you had your privileges to practice in a hospital revoked, withdrawn, or not renewed as a result of professional misconduct or incompetence or have you resigned your hospital privileges while under investigation in respect of such a matter?

Have you had your privileges to practice in a hospital revoked, withdrawn, or not renewed as a result of professional misconduct or incompetence or have you resigned your hospital privileges while under investigation in respect of such a matter? Yes No
Please explain
Educational Supports
How can Schulich School of Medicine & Dentistry enhance your experience as a Preceptor?
Are there any obstacles that you have encountered as a Preceptor?
Are you interested in pursuing any of the following?

Are you interested in pursuing any of the following? Continuing Medical Education Faculty Development Leadership Development Leadership Roles
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 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

(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.)
Additional Comments
Current CV
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Clinical Faculty (MD) Reapplication Form

Clinical Faculty (MD) Reapplication Form

Personal Information

Practice Information

Home Information

Western Information

Activity Summary

Research Experience and Interest

License Information

Attestations

Hospital Information

Educational Supports

Current CV