TO THE CANADIAN BOARD OF OCCUPATIONAL MEDICINE. Please make cheques payable to the Canadian Board of Occupational Medicine

Transcription

1 TO THE CANADIAN BOARD OF OCCUPATIONAL MEDICINE Please check either box A, box B or box C. A. APPLICATION FOR FELLOWSHIP STATUS 0 Non-refundable fees are: $350 for eligibility assessment; $350 for the examination. B. APPLICATION FOR CERTIFICATE STATUS 0 Non-refundable fees are: $350 for eligibility assessment; $350 for the examination. C. APPLICATION FOR ASSOCIATE STATUS 0 Non-refundable fees are: $350 for eligibility assessment; $350 for the examination Please make cheques payable to the Canadian Board of Occupational Medicine l.n~: ~~~ ~~~ ~~~ Last Name First Name Middle Name 2. MAILING ADDRESS: 3. TELEPHONE NO. FAX NO ~ ADDRESS 4. LICENSED BY: province / territory 5. LICENCE NUMBER: 6. NAME: The name should be given here in the way you would want it to appear on the certificate. Include degree(s) if desired. Attach an autographed photograph here rev rev rev. 2000

2 - SUMMARY OF EDUCATIO N AND EXPERIENCE 7. Pre-Medical Education: University From (Month & Year) To (Month & Year) De ee(s) 8. Medical School: University From (Month & Year) To( Month & Year) De ee 9. Other Graduate Education: University or College From (Month & Year) To( De ee s 10. Clinical Training: (Internship and Residency): Hospital Location Type oftra Occupational or Preventive Medicine Residency or Formal Training: (see also 17b) Institution Location Type of Specialty Residency Program Director From: (Mo. & Yr.! -

3 12. Occupational Medicine Practice (list chronologically): From (Mo. & Yr.) To (Mo. & Yr.) Activity Years Claimed 13. Other Professional Practice (list chronologically): From (Mo. & Yr.) To (Mo. & Yr.) Activity Years Claimed 14. Military Service: Branch of Nature of From (Mo. & Yr.) To (Mo. & Yr.) Service Rank Activities 15. Licensed to Practice Medicine: How Obtained: How Obtained: Province Exam Reciprocity Year License Number 16. Present Position: Are you now engaged in full-time Occupational Medical activities? Yes No (1) State the average number of hours per week and the percentage of your total practice which you devote to Occupational Medicine: (2) Professional activities, if any, not related to Occupational Medicine. Be specific.

4 17. Graduate Training in Occupational Medicine: (a) Academic (Transcript Required) University or From (Mo. & Yr. To (Mo. & Yr.) Institution Field of Training Degree or Diploma (b) Residency: Supervised full-time field training in Occupational Medicine (in chronological order): From (Mo. & Yr.) To (Mo. & Yr.) Position held (title): Location of training: Program Director: Immediate Medical Supervisor: From (Mo. & Yr.) From (Mo. & Yr.) Position held (title): Location of training: Program Director: Immediate Medical Supervisor: From (Mo. & Yr.) To (Mo. & Yr.) Position held (title): Location of training: Program Director: Immediate Supervisor: (Use additional sheets if necessary)

5 18. Practice in Occupational Medicine (See also: APPENDIX A) From (Mo. & Yr.) To (Mo. & Yr.) Position held (title): Location: Full Time Part Time If part time, specify hours per week Area and no. of population served: No. of staff members under your supervision: If other professional activities than above, describe these and indicate hours per week: From (Mo. & Yr.) To: (Mo. & Yr.) Position held (title): Location: Full Time Part Time If part time, specify hours per week Area and no. of population served: No. of staff members under your supervision: If other professional activities than above, describe these and indicate hours per week: From (Mo. & Yr.) To (Mo. & Yr.) Position held (title): Location: Full Time Part Time If part time, specify hours per week Area and no. of population served: No. of staff members under your supervision: If other professional activities than above, describe these and indicate hours per week: (Use additional sheets if necessary)

6 19. Clinical or related training: From (Mo. & Yr.) To (Mo. & Yr.) Location Describe Type of Practice 20. Teaching experience in Occupational Medicine, if any: Hours Academic Nature of Teaching Per From (Mo. & Yr.) To Mo. & Yr.) School Rank or Title Activities Week 2l. Research Experience a. Organizations, ocations and dates: b Specific problems and nature of participation: (Use additional sheets if necessary)

7 22. List all CME credits (Use additional sheets if necessary) 23. If certified in a recognized College or specialty board, specify with date certified: 24. Membership on technical and advisory committees to associations and service organizations: 25. Special honors, awards, offices held in professional societies: (Dates) 26. Professional Publications: List on separate sheet. Do not use reprints 27. Names and addresses of three practicing occupational physicians (one of whom must hold a certificate of the Canadian Board of Occupational Medicine) from whom information may be obtained regarding your qualifications. Do not submit letters of reference. Name: Address: Name: Address: Name: Address:

8 I hereby apply to you for the granting of Fellowship status, Certificate status (or Associate status), pursuant to and subject to the terms and provisionsof your letters patent, by-laws and other regulations, as are, from time to time, in force (hereinaftercollectivelyreferred to as your rules and regulations) by all of which I agreeto be bound. As the fees payable in connectionwith this application,ienclose herewiththe sum of$ and agree to pay the additional sum of $ at or before the time of such examinationas Imay be requiredto take pursuantto your rules and regulations,andiagree that no fee paid by me shall be refundable. To induce you to accept and act upon this application, I further covenant and agree (1) to indemnify and hold harmless you and each and all of your members, trustees, officers, examiners, and agents from and against any liability whatsoever in respect of any act or omission by you or them or any of them in connection with this application, such examination, the grades given upon such examination, and/or granting or issuance or failure to grant or issue Fellowship status, Certificate status or Associate status to me, and (2) that any document of membership which may be granted and issued to me shall be and remain your property. I WARRANT THAT EACH OF THE STATEMENTS MADE IN SUPPORT OF THIS APPLICATION IS TRUE AND CORRECT. Signature Date AUTHORIZA non Ihereby authorize the Canadian Board of Occupational Medicine to request reference letters and develop information from any of the persons or organizations referred to in this application and to verify academic and/or residency and clinical training deemed necessary to make a determination of my eligibility. Signature Dffie

9 CANADIAN BOARD OF OCCUPATIONAL MEDICINE APPENDIX A: SUMMARY OF OCCUPATIONAL MEDICINE ACTIVITIES NOTE: Part-time or casual occupational medicine practice will not be considered for the CBOMlACBOM time eligibility unless there is evidence of a specific contract or a specific allotment to perform only occupational medicine practice. Performance of occasional work-related services within a regular family medicine practice does NOT constitute evidence of a special interest in occupational medicine. HOURS ACTIVITY (e.g. company, clinic) START END PER HOURS DATE DATE WEEK CLAIMED