Mac-CARE ROTATION REQUEST FORM - PGME Learners only

UGME Medical Students - click here for further information

Please note that required fields are marked like this:

LEARNER INFORMATION

Learner Last Name
Learner First Name
Gender Male    Female   Other:
Residency School    Other:
Academic Home/Campus Base
Student ID Number
CPSO#
CMPA#
MINC# (if available)
Level of Learner
PGY-1
PGY-2
PGY-3
PGY-4
PGY-5
PGY-6
PGY-7
Clinical Fellow
Please note 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
Learner Email
Learner Home Phone
Learner Mobile Phone

ROTATION INFORMATION

Rotation Specialty
Core
Elective
Selective
Rotation Start Date
Rotation End Date
Rotation Prearranged
Yes by
No
Preceptor Name and Location (List all that apply)
Preceptor Phone
Preceptor Email
Preceptor Fax
Additional Rotation Specialty (e.g. Selective added to Core Request)
Vacation approved for learner during rotation
No
Yes
Start End
Submitted By Name
(First and Last Name)
Submitted By Email
(Email Address)
Date Submitted

Rotation Site

Campus Site Communities within Campus Funding
Hamilton City of Hamilton no funding
Mac-CARE Communities
Burlington Burlington no learner funding at this site *
Grand Erie Six Nations Brantford
Caledonia
Delhi
Dunnville
Hagersville
Ohsweken
Paris
Simcoe
Halton Georgetown
Milton
Oakville
no learner funding at Oakville site *
Niagara Beamsville
Fort Erie
Grimsby
Niagara Falls
Niagara-on-the-Lake
Port Colborne
St. Catharines
Smithville
Welland
Waterloo Cambridge
Drayton
Fergus
Guelph
Kitchener-Waterloo
Mount Forest
Palmerston
Brampton
& Etobicoke
Brampton
& Etobicoke William Osler Teaching Sites
no learner funding at Brampton & Etobicoke sites *
* Please reference Mac-CARE Travel & Housing Policy
First Choice
Burlington Clinical Education Campus
Grand Erie Six Nations Clinical Education Campus
Halton Clinical Education Campus
Niagara Regional Campus
Waterloo Regional Campus
Brampton/Etobicoke Community Teaching Site
Second Choice
Burlington Clinical Education Campus
Grand Erie Six Nations Clinical Education Campus
Halton Clinical Education Campus
Niagara Regional Campus
Waterloo Regional Campus
Brampton/Etobicoke Community Teaching Site
Third Choice
Burlington Clinical Education Campus
Grand Erie Six Nations Clinical Education Campus
Halton Clinical Education Campus
Niagara Regional Campus
Waterloo Regional Campus
Brampton/Etobicoke Community Teaching Site

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?
No   Yes    If yes, please explain:
Have you ever been disciplined by a university or medical authority?
No   Yes    If yes, please explain:
Have you ever had your medical license suspended or revoked in any jurisdiction?
No   Yes    If yes, please explain:
Additional Documents that will be required upon confirmation of elective placement:
Proof of current immunizations (Out-of-Province Postgraduate trainees)
Proof of current mask fit test
Letter of support from your program director
Letter from McMaster program director/supervisor (Mac-CARE communities are exempt)


All Out-of-Province Postgraduate Trainees must complete the following:

  • Complete the PG McMaster Health Screen Record and submit to McMaster University Health Screening Office at least 8 weeks prior to your start date to allow for processing and clearance. Health Screen Record and instructions for submission may be found on the FHS Health Screening website.

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

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