ࡱ> LNKe bjbj .abab 9X X 4hp440"""///////$1n4/`""``/4/%%%`/%`/%%Vu-@9.jĕj- y//00-x5L59.59.@"%00"""//""""0````5"""""""""X B : In-Coming Elective Registration Form Return completed form to U of A Residency Program Director for signature along with letter from residents home Program Director at least 3 months prior to the start date of the elective, 6 months if requiring a Work Permit with a CV included (Passport number will be required & speedcode) Name: ________________________________________________ Last Name First Name Home Address/Phone: _____________________________________ _ Street/Avenue City/Province Postal Code Phone Number ____________ E-mail _________________ _______ Date of Birth: ________________ Citizenship: ________________________________ Day/Month/Year Medical School: ________ ___________ Year of MD Graduation: ________________ Elective Program (U of A): _______________________________________________ Elective Start Date: ____ __ Elective End Date: _______ Previously licensed with CPSA (College of Physicians & Surgeons of ϲ) Yes _____ No _____ Site(s) elective will be held at ( UAH ( RAH ( GNH ( MIS ( Stollery ( Other Program Director at Residents Home Institution (name and mailing address): ___________________________________________________________________ Name Department University ____________________________________________________________________ Street/Avenue City Province Postal Code ϲ Program Director (Please print) ______________________________ U of A Program Directors Signature: Phone Number ______________________ Date ______________________________ An in-coming Resident Elective is a trainee who is enrolled in an accredited Postgraduate Medical Education program at another institution and is coming to the ϲ to undertake a segment of their training. The training they receive at the ϲ is to be evaluated and counted towards their training program at their home institution. All Resident Electives are required to sign a standard Postgraduate Medical Education Agreement. Unless they are from the University of Calgary, they are also required to be placed on the Educational Register of the College of Physicians and Surgeons of ϲ (CPSA). For International electives over 90 days, English language requirements must be met according to CPSA including Physicians Apply source verification. CMPA coverage is mandatory; residents should contact CMPA to add the ϲ to their coverage. Home Program Director elective approval letter attached Completed N95 and PPE simulation training Check box only if connectCare access is required All personal information requested on this form is collected under the authority of the Universities Act and section 33(c) of the Freedom of Information and Protection of Privacy Act, and is used for the purposes of academic administration and human resource management. Questions concerning the collection, use or disposal of this information should be directed to: Administrative Manager, Postgraduate Medical Education, 2-76 Zeidler Ledcor Centre, ϲ, T6G 2X8, phone (780) 492-9722, fax (780) 492-4144.     Office of Postgraduate Medical Education Faculty of Medicine and Dentistry 2-76 Zeidler Ledcor Centre ϲ ( Edmonton ( ϲ ( Canada ( T6G 2E1 Telephone: (780) 492-8076 Fax: (780) 492-4144  HYPERLINK http://www.med.ualberta.ca www.med.ualberta.ca %&;?Bn ; G H I J P Q U    * + 1 3 D E L M [ ƽxxss hPyD>*hPyDhPyD5aJ h1lCJ ha>* h$(>* h1l>* h5 h1l5 h1l5CJh7h1l5CJaJh 5CJaJh5CJaJ hF5CJ h5CJ ha5CJh7h75CJh7h1l5CJhB|,h1lCJaJ h1lCJ,%&I J ccc-$ d$d%d&d'dNOPQa$-$ d$d%d&d'dNOPQa$9$ d$d %d&d 'd-DM N OP Qa$gd7$a$  M \ . / }}P}},$ x$d%d&d'dNOPQa$*$ $d%d&d'dNOPQa$/$ dx$d%d&d'dNOPQa$&$$d%d&d'dNOPQa$ [ \ l x | }     ) - . / @ I K L {   " huCJaJhQnCJaJ hQn5huhQnCJaJ hr>* hm>* h1l5CJ h$(>* h1l5CJ h1l>* h_j5 ha>*hah$(>*hah1l>* h1lCJh$(hah1l h1l5h1l5>*CJ3 5 GGG9$ u$d%d&d'dNOPQXD<^`ua$gdu)$$d%d&d'dNOPQa$gdQn($<$d%d&d'dNOPQa$*$ $d%d&d'dNOPQa$" ' ( 5 [ \ ] e f o p y z ) * L N EGPQ]uyе󡝘}}umhBPCJaJhB|,CJaJ h1l5\h1l5>*CJ h1lCJ h$(>* h1l>*h1l h1l5 jhah65CJaJhah65CJaJ jhah*h;h1jh1UhQnh1lCJ hCJ h;8CJ h7CJ hqCJ h1lCJ hiJCJ1%@~$a$gdQn$a$$a$ $BhQnh1lCJh1h;>PP&P1+:pB|,/ =!"#$%@@ M 0PP&P/ =!"#$% P0 E 0PP&P1+:pBP/ =!"#$% P DyK www.med.ualberta.cayK 8http://www.med.ualberta.ca/s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH D`D NormalCJOJQJ_HmH sH tH D@D  Heading 1$@&5CJOJQJll  Heading 28$$ d$d %d&d 'd-D @&a$5CJDA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 4@4 Header  !4 @4 Footer  !:B@: Body Text 5OJQJ0U`!0 Hyperlink>*B*8P@28 Body Text 2$a$BQBB Body Text 3$da$CJB>@RB Title$ da$5CJ"TObT bullet# & F hh(^h`( 5CJ\HrH 7 Balloon TextCJOJQJ^JaJFV F fiFollowedHyperlink >*B*phOrPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<  .@.. 468888888888888;[ " )  Q $;X@ @H 0(  0(  B S  ?7777777777777777{ @ N X X c m v       J U ` j s } }    >*urn:schemas-microsoft-com:office:smarttags PostalCodeB*urn:schemas-microsoft-com:office:smarttagscountry-region9 *urn:schemas-microsoft-com:office:smarttagsState8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType   >G d k l r &' 333%%&'-noHIIJJPQTTU*+13DELR[\\rrx|}} -?HL{)+/12?KLMN;KMO  ln   ' 7 % @ { } HIIJJTTU*++3DELSSWW\\rrx|-L{'(115)N   ! 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