Pathway 41).pdfPathway 4 - Instruction Guide Page 1 of 12 Revised: September 2012 Dear Applicant, The College is pleased to provide you with an application

Pathway 4 - Instruction Guide Page 1 of 12 Revised: September 2012

Dear Applicant,

The College is pleased to provide you with an application package to apply for a certificate of registration under the College’s Pathway 4 policy.

Pathway 4 leads to a certificate of registration authorizing independent practice in the applicant’s field of practice without the usual requirement for certification by examination by the Royal College of Physicians and Surgeons of Canada (RCPSC) or the College of Family Physicians of Canada (CFPC). It requires an initial one-year period of supervised and mentored practice followed by successful completion of a practice assessment.

Pathway 4 prerequisite qualifications are as follows:

Medical degree from an acceptable medical school outside Canada or the USA

United States Medical Licensing Examination (USMLE), or an acceptable alternative – see enclosed Schedule of Requirements for details

Residency in the USA accredited by the Accreditation Council for Graduate Medical Education (ACGME)

Certification as a specialist by the American Board of Medical Specialities in your scope of practice

Currently hold, or be eligible to apply for, an independent or full licence or certificate to practise without restrictions in the USA

If you meet all these prerequisite qualifications and wish to apply, please note that your application will need to be reviewed and approved by the College’s Registration Committee. No assurances can be offered regarding Registration Committee review, and therefore you should not make any firm commitments to start practising in Ontario by a particular date.

If you are missing any of the prerequisites you are not eligible to apply under this pathway. You should inquire about your eligibility under the College’s other registration policies.

This application package contains the following:

Instruction Guide: Application Rules and Timelines Schedule of Requirements Requirements Checklist Registration Committee Meeting Dates

Forms: Application Form Credentialing Forms Payment Form

Should you have any questions, please contact the Inquiries Section in the Applications and Credentials Department at (416) 967-2617, Monday to Friday 9:00 am to 5:00 pm. Depending on when you call, you may experience a short wait in the queue.

The College looks forward to receiving your application, and wishes you a successful and rewarding practice in Ontario.

Sincerely,

Inquiries Section Applications and Credentials Department


Pathway 4 APPLICATION RULES AND TIME FRAMES Please note the following rules and time frames of the College’s registration process. They apply to all applicants and must be followed carefully to enable efficient and timely processing of your application.

Submitting your Application You are responsible for your application and for completing all requirements exactly as instructed. Incorrect

or missing information must be corrected and will delay your application.

Submit your application form and fee and begin arranging for all supporting documents at least four months in advance of your intended starting date.

Mail or courier your application and payment to the College. Faxed applications are not acceptable and no action will be taken on them.

Upon receipt of your application we will email you log-in instructions for our Online Application Status Check.

Assessment of your Application and Online Status Check Applications are assessed in the order they are received. March to July is our peak period.

Wait time between receipt of application and completion of initial assessment is usually five to seven weeks, but can be longer during our peak period.

You can check online for our receipt of your application documents. However, your documents are not deemed complete until they have been assessed and approved.

Following assessment, we will update the status of your documents online and will indicate any missing documents. Be sure to advise us immediately if you change your email address.

It remains your responsibility to check your application status. We do not send regular reminders.

If our initial assessment of your application indicates missing information or matters requiring further review, you may be asked for additional supporting documents not listed in the schedule of requirements.

Supporting Documents

Do not delay in arranging for all required supporting documents as listed in the schedule. Note that any affirmative responses to section 9 in the application form will also require supporting documents.

Some documents, e.g. evidence of standing, have a six-month term of validity and may require updating.

Documents received at the College take one full business day to be logged and to appear in the Online Status Check. We are unable to confirm receipt of a document or fax until then.

Ensure that all required primary-source verifications of your credentials are sent directly to the College from the source. Verifications sent by you or via a third party will be rejected. Faxed verifications are acceptable only if they have been faxed directly by the source and clearly indicate the source organization. If we are unable to verify the sender of the document, or if the sender does not meet our requirements, you will be required to arrange for re-sending.

Registration Committee Review The Registration Committee meets once every four to six weeks, with a five-week cut-off date preceding

each meeting. Credentialing must be completed before applications can be referred to the Committee.

The Registration Committee staff will correspond with you regarding any specific information and documents that will support your application and assist the Committee in its review.

No assurances can be offered regarding outcome of review. After Committee review, you will be advised in writing of the outcome. Approved applications are returned to the Applications and Credentials Department for collecting follow-up documents and issuing your certificate. Allow up to two weeks for this process.

Carefully review the enclosed Registration Committee Meeting Dates document.


Non-Exemptible Requirement for Registration

In addition to the requirements listed in the schedule, every applicant for registration must satisfy the following non-exemptible requirement:

The applicant's conduct, including past conduct, affords reasonable grounds for belief that the applicant: (i) is mentally competent to practise medicine; (ii) will practise medicine with decency, integrity and honesty and in accordance with the law; (iii) has sufficient knowledge, skill and judgment to engage in the medical practice authorized by the

certificate, and (iv) can communicate effectively and will display an appropriately professional attitude.

If any issues are presented that call into question an applicant's compliance with this requirement, that matter will also need to be reviewed by the Registration Committee.

Issuance of Your Certificate

The College makes every effort to register applicants in time for their planned start date, but delays outside our control can occur, e.g. missing supporting documents, and therefore applicants should not make any firm commitments to start practising by a particular date.

Applications remaining incomplete or in process for six months will require updating. Applications remaining incomplete and inactive for more than one year will be considered withdrawn.

Practising without a valid certificate of registration is an offence in Ontario. Upon issuance of your certificate, you will be sent email notification. Your hard-copy certificate will be mailed to you afterwards.

If you have completed all requirements but have not received confirmation of issuance of your certificate, you must contact the College to confirm that you are registered. Do not rely on third-party information.

You can also verify your registration status on our website. Once you have been registered with the College, your profile, including CPSO registration number, will appear under the Doctor Search feature of our website. You can find your profile by doing a name search. If your name does not appear with “active member” status, you have not yet been registered.

Provide your Ontario mailing address as soon as possible to avoid delays in receiving your certificate.

Terms, Conditions and Limitations of the Restricted Certificate of Registration

Upon completion of all application requirements and approval by the Registration Committee, the College will issue you a Restricted certificate of registration.

Each Restricted certificate issued under Pathway 4 will have the following general terms, conditions and limitations imposed by the Registration Committee. Necessary details to reflect your situation will be added by the Registration Committee at the time of review of your application:

1. The physician must practise with a supervisor and mentor until he or she has successfully completed an assessment.

2. The physician must undergo an assessment after completing a minimum of one year of practice. The certificate automatically expires 18 months from the date of issuance, but may be renewed by the Registration Committee, with or without additional or other terms, conditions and imitations.

In addition to those imposed by the Registration Committee, every certificate issued by the College carries the following standard term, condition and limitation:

The holder may practise only in those areas of medicine in which he or she is educated and experienced.

Any practice outside the physician’s area of education and experience would contravene the certificate’s terms, conditions and limitations. If the physician intends to change scope of practice, he or she must follow the College’s Change of Scope of Practice policy by participating in a training process that will ensure safe and competent practice in the new area.


Specialist Recognition

The College’s rules on recognition of specialists are set out in its policy, “Specialist Recognition Criteria in Ontario.” All applicants should read this policy posted on the College’s website under Registration Policies. Only those physicians who meet the criteria in this policy can be recognized by the College as specialists.

Fee for Service Billing Number Eligibility for a fee-for-service billing number in Ontario is contingent on issuance of the Restricted certificate. Billing numbers are issued by the Ontario Ministry of Health and Long-Term Care. For further information about obtaining an Ontario Health Insurance Plan (OHIP) number visit the Ministry's website at www.health.gov.on.ca.

Practice Assessment

After the initial one-year period of supervised and mentored practice, satisfactory completion of on-site practice assessment is required. An on-site assessment organized by the College takes at least two days. You must follow any practice recommendations arising from assessment.

All costs associated with the practice assessment are borne by the applicant.

If practice assessment is not successful, the Restricted certificate automatically expires at 18-month point, but may be renewed by Registration Committee with or without additional terms, conditions, limitations.

Annual Renewal of the Certificate Upon completion of successful practice assessment, you will be issued a certificate of registration authorizing independent practice restricted to the area of medicine assessed.

To maintain the Restricted certificate of registration, a member must renew his or her membership each year through full payment of annual membership fee and completion of the mandatory membership renewal form.

The College does not offer reduced membership fee for members on leave, residing outside Ontario, or otherwise not using their certificate.

The College’s membership year is June 1 to May 31. For new members registered partway through the membership year, the subsequent annual fee will be reduced by a pro-rated amount.

Should a member choose to resign from membership or allow the certificate to expire for failure to complete the annual renewal requirements, he or she cannot resume medical practice in Ontario without applying and qualifying for a new certificate of registration.


Pathway 4 SCHEDULE OF REQUIREMENTS

This schedule contains the requirements for registration under Pathway 4.

PART A - The requirements to be returned by you with your application form.

PART B - The requirements you must arrange to be completed by the source organization. All requirements in this schedule must be completed. Please ensure that you follow instructions carefully.

PART A: Requirements to be submitted with your Application

1) Application Form

Your application form must be fully completed and the declaration on the last page must be signed and sealed by a commissioner for oaths, notary public, or lawyer. If the lawyer does not use a seal, a business card must be attached. An incomplete form or a form not properly notarized will be returned.

Ensure that your photograph is full face, of passport size and quality, and taken within sixty days of completing the form. A photograph not meeting these specifications will be returned.

In part 9, read the instructions and answer each question carefully. Every ”yes” response must be explained in writing and supported by the required background documents or third-party reports. Processing of these applications usually takes longer, and therefore we encourage such applicants to apply early.

Any missed questions or incorrect responses will require correction and may delay your application. Any conflicting or false responses will require written explanation.

Applications not completed after one year will be considered withdrawn.

Although the form is titled “Application for an Independent Practice certificate,” it will be treated as an application for a Restricted certificate under this Pathway.

2) Medical Degree from an Acceptable Medical School

A legible photocopy of your medical degree from an acceptable medical school outside Canada or the USA (see page 11 for definition).

An official translation is required if the medical degree is not in English or French (see page 11 for acceptable translations). All translations must be accompanied by a copy of the original document in the language of issue.

3) Current Practice Description and Ontario Practice Plans

Complete and return the enclosed form, “Current Practice Description and Ontario Practice Plans.”

This form will assist the College in determining whether you meet the requirement that you currently hold, or be eligible to apply for, an independent or full licence or certificate to practise without restrictions in the USA.

It will also assist in assessing whether the nature of your present practice outside Ontario and your intended practice in this province present any concerns with respect to change of scope, continuity and recency of practice.


Schedule of Requirements – Pathway 4

4) Independent or Full Unrestricted Licence in the USA (or proof of eligibility)

Photocopy of your current independent or full licence or certificate to practise medicine without restrictions in a state in the USA. If more than one, provide a photocopy of each.

If you do not currently hold an independent or full licence or certificate to practise medicine without restrictions in the USA, you must provide clear, written proof and supporting documentation that you are currently eligible for such a licence or certificate in a state in the USA.

5) Consent to Disclosure of Criminal Record Information

A criminal record check using the Canadian Police Information Centre (CPIC) database is required, using one of the following two options. Use Option B if you are outside Canada.

Option A: Make your own arrangements to obtain a valid CPIC check from a municipal or provincial police service in Canada. Online checks by third-party commercial vendors are not accepted. For further instructions see the Consent form.

Option A is strongly recommended, especially if you have an urgent starting date.

Ensure your CPIC check covers convictions and current charges – both are required. Please check this with the police service. Some police services (e.g. London police service) do not report current charges in their basic CPIC check, in which case you must ask for a vulnerable persons check or use a different police service.

Option B: For the College to obtain a CPIC check on your behalf, submit the following: Completed consent form Photocopy of two pieces of government-issued ID, such as a current passport, birth

certificate, valid driver’s licence, permanent resident card or Canadian citizenship card. If using a card, please provide a photocopy of the front and back.

Payment of processing fee of $15. Payment must be made by Visa, American Express, MasterCard (using the College form) or by money order or certified cheque payable to CPSO. Note that personal cheques are not accepted.

The College will obtain a CPIC check on your behalf from the Ontario Provincial Police - minimum 15 business days processing time and cannot be expedited. For further instructions see the Consent form.

If your check indicates a possible match in the CPIC system, fingerprint verification from the Royal Canadian Mounted Police (RCMP) will be required to complete the screening process. You will be notified if this applies to you.

6) Canadian Citizenship, Permanent Resident Status or Work Permit

One of the following is required:

(i) Proof of Canadian citizenship (photocopy of your Canadian birth certificate, Canadian baptismal certificate, Canadian passport or Canadian citizenship card). Date of birth must be shown.

(ii) Proof of Canadian Permanent Resident status under the Immigration and Refugee Protection Act (photocopy of both sides of your Permanent Resident card issued by Citizenship and Immigration Canada).

(iii) Photocopy of a valid Canadian Work Permit issued under the Immigration and Refugee Protection Act, which permits you to practice medicine and is consistent with your supervised practice arrangement in Ontario. Submission of your work permit may be the final requirement.



7) Notarized Copy of your Current Passport (if applicable)

If you are not a Canadian citizen or permanent resident, you must submit a notarized copy of your passport. The copy must be a certified true copy of the original, and the notary public or lawyer must attach a seal or other evidence verifying notary public status. A passport stamped by a Canadian embassy overseas is also acceptable. Ensure that your notarized copy includes the pages containing your photograph, personal details, issuing country and passport expiry date.

8) Evidence of Name Change (if applicable)

Evidence of all official name changes must be submitted with your application (i.e. marriage certificate, official court order). In entering your name on the register, the College will use the name provided on your medical school documentation and supported by other identification documents unless you have officially changed your name.

9) Declaration for Breaks in Training or Practice History

Using the Declaration form provided by the College, you must declare every break of six months or more in your postgraduate medical training or practice history.

Be sure to include any delays occurring between the date of your graduation from medical school graduation and commencement of your postgraduate training. Time spent in research and observerships should be declared.

A new form must be submitted with each application made to the College. Please ensure the dates provided are correct and match your application form and curriculum vitae. Missing periods or conflicting dates will require clarification and completion of a new form.

If you have not practised for the past three years or practised less than six months over the past five years, your application will require review by the Registration Committee under the College’s Re-entry to Practice policy. For further details relating to this policy, visit the College’s website at www.cpso.on.ca, follow the Policies and Publications link from the home page.

In the application form you must also disclose all breaks of six months or more. Also, all medical leaves of absence must be disclosed, even those less then six months in duration.

10) Professional Liability Protection – Declaration or Undertaking

All applicants must have adequate professional liability protection, either from the Canadian Medical Protective Association (CMPA), an Ontario insurance company, or under the Treasury Board Policy for Indemnification Crown Servants of Canada.

(i) Using the Declaration: Professional Liability Protection form provided by the College, you must declare that you have professional liability protection that complies with the College’s by-law. See the Declaration for further instructions.

(ii) If you do not yet have professional liability protection in Ontario, complete the Undertaking: Professional Liability Protection form provided by the College. Applicants seeking CMPA coverage for the first time will need to complete the Undertaking. See the Undertaking form for further instructions.

Although you can be registered by the College based on your Undertaking, you must not commence any medical practice until you obtain professional liability protection. After you obtain it, you must submit a Declaration by Member to the College within 30 days. The Declaration by Member will be mailed to you by the College with your certificate of registration.



11) Report from the National Practitioner Data Bank (NPDB) and Healthcare Integrity and Protection Data Bank (HIPDB)

If you have practised medicine or taken postgraduate medical training in the United States, a “Self-Query” of NPDB-HIPDB is required.

You must submit to NPDB-HIPDB a Self-Query request for information disclosure, and then forward to the College the report you receive from NPDB-HIPDB.

If you receive a rejection notice from NPDB-HIPDB, do not forward it to the College. Instead, re-submit your Self-Query to NPDB-HIPDB.

Note that the Self-Query must be submitted through the NPDB-HIPDB website. For further instructions and to start the Self-Query process, go to www.npdb-hipdb.hrsa.gov.

12) MINC Consent Form

The MINC number is a national identifier unique to each physician in Canada, but contains no encoded personal information. It is used by approved Canadian medical regulatory, administrative and research bodies. See enclosure for further information.

Your completed MINC Consent form will enable the CPSO to arrange for issuance of your MINC number. If you already have a MINC number or are not sure whether you have one, please provide your MINC Consent. Only with your Consent can we check for your existing MINC number.

13) Curriculum Vitae

Your current curriculum vitae must provide: (i) Undergraduate medical education information and date of graduation (ii) A listing, in chronological order (month/year) of all your postgraduate training appointments

including, duration and level of training in every jurisdiction since graduation (iii) A listing, in chronological order (month/year) of all your professional appointments and type of

practice including names of hospitals and/or clinics, discipline, duration and location (please specify the city, province/state, country)

(iv) A listing of all your previous and current medical licences including type, duration, licence number and jurisdiction

(v) A listing of specialist and other postgraduate examinations and qualifications

Any significant gaps in your training and practice history must be explained in the curriculum vitae.

14) Payment of Fees ($2300.00)

Application Fee (non-refundable): $770.00

Membership Fee: $1530.00

Total fees payable are $2315.00 if using Option B for CPIC check.

Fees must be submitted with your application. No assessment of your application will be made until the application fee is received. The application fee is non-refundable regardless of whether your application is incomplete, withdrawn or refused.

Payment must be made using Visa, American Express, MasterCard, money order or certified cheque (payable to the College of Physicians and Surgeons of Ontario). Please use the form provided by the College to authorize payment of fees by Visa, American Express or MasterCard. Personal cheques are not accepted.

Receipt of your payment of fees by the College does not confirm that you are eligible for registration nor does it confirm that your certificate of registration has been issued.

Fees are subject to change. Applications are subject to fee amounts in effect at time of submission.


PART B: Requirements to be sent by Source Organization

You must arrange for the documents below to be sent directly to the College by the source organization.

Source documents sent by you or via a third party will be rejected. They must arrive by mail in an official, sealed and stamped envelope from the source organization. Courier delivery is acceptable, but the documents inside the courier package must be in an official

envelope that has been sealed by the source organization. Courier packages must be sent directly to the College.

Source documents not written in English or French must be supplemented by English or French translations obtained by the applicant. See the Notes section of this schedule for further details.

Documents not meeting these requirements will not be accepted.

15) Medical School Transcript

Arrange for an official sealed transcript verifying your undergraduate medial education and conferral of degree in medicine.

If you attended more than one medical school, an official transcript will be required from each school. You must also arrange for a letter from the first school confirming that your transfer was voluntary and that you were in good standing at the time of transfer.

Alternatives (a) If your medical school does not issue official transcripts, you must instead arrange for the

school to complete a Certification of Medical School Graduation form. Blank forms are available from the College.

(b) Physicians Credentials Registry of Canada (PCRC) Source Verification – The College will accept source verification of your medical degree credentials if completed by PCRC. If you have completed source verification with the PCRC, arrange for PCRC to share your verified credentials with the College.

(c) Federation Credentials Verification Service of the U.S. Federation of State Medical Boards - If you have completed source verification with FCVS, arrange for FCVS to send your “Physician Information Profile” directly to the College.

16) United States Medical Licensing Examination (USMLE) or other Acceptable Qualifying Examination

The official acceptable alternative examination results must be sent from the Examining Office.

Acceptable alternatives are as follows: (i) MCCQE passed before December 31, 1991 (i.e. before the introduction of Parts 1 and 2). (ii) US National Board of Medical Examiners (NBME) exams passed before December 31, 1994. (iii) Licensing Examination of the US Federation of State Medical Boards (FLEX) passed before

December 31, 1994, with a score of 75 on each of Components 1 and 2. (iv) USMLE Steps 1, 2 and 3. Step 2 Clinical Skills (CS) is also required if you took Step 2 after

June 12, 2004. (v) ECFMG certification (based on USMLE Steps 1 and 2) plus USMLE Step 3. USMLE Step 2

Clinical Skills Assessment (CSA) component is required if ECFMG certification was obtained between July 1, 1998, and June 14, 2004.

(vi) The Comprehensive Osteopathic Licensing Examination (COMLEX-USA) Levels 1, 2 and 3. COMLEX-USA Level 2 Performance Evaluation (PE) component is required if Level 2 was completed after September 2004.

(vii) Examen Clinique Objectif Structuré (ECOS) of the Collège des Médecins du Québec passed between 1992 and 2000.

17) Letter from Supervisor

Before your application can be reviewed by the Registration Committee, your prospective supervisor in Ontario must submit details of your proposed practice along with an outline of the supervision arrangement that satisfies the Guidelines for College-Directed Supervision. For further details relating to supervision, visit our website at www.cpso.on.ca, follow the Registration link from the home page.



18) Completion of Accredited Residency in USA

You are required to have completed a full residency program accredited by the Accreditation Council for Graduate Medical Education in the USA. Arrange for a report to be sent to the College by your residency program. The report must specify your dates of enrolment, discipline, and training performance in the residency program.

19) Certification as a Specialist by a US Specialty Board

You are required to have current certification as a specialist by a member board of the American Board of Medical Specialties. Arrange for verification of your current specialty certification to be sent to the College by the Board concerned. If you are currently certified in more than one specialty, arrange for verification to be sent for each certification.

20) Evidence of Standing and Independent Practice Licence

Using the “Confirmation of Standing” form provided by the College, you must provide evidence of good standing from the medical licensing authority in every jurisdiction where you have practised medicine, or have taken postgraduate training. If the form received does not cover your full period, a revised form will be required.

The evidence of good standing from the USA must also confirm that you currently hold an independent practice or full licence or certificate to practise without restrictions in a state in the USA. (Alternatively, you must provide clear written proof and supporting documentation that you are currently eligible for an independent or full licence or certificate to practise medicine without restrictions in a state in the USA – see requirement (4) in this Schedule).

A certificate of standing is acceptable in lieu of a completed “Confirmation of Standing” form only if the licensing authority will not complete the Confirmation form and only if the certificate of standing attests to the same information as required on the Confirmation form.

If you were not required to hold a licence to practise or train medicine in a jurisdiction, you must arrange for a letter from your Program Director or Supervisor. It must be sent directly to the College in an official, sealed and stamped envelope. It must confirm the dates of your appointment, type of position, satisfactory performance and conduct and that no registration or licensure was required.

21) Reference Forms

Using the Reference Form provided by the College, please arrange for three references to be completed by the following individuals at the hospital where you presently practise: Chief of Staff; Department Head; Head Nurse. If your current practice is not hospital-based, please arrange for three references from physicians in authority who can comment on your current practice, e.g. Medical Director or most senior physician at your clinic. A photocopy of your Final In-Training Evaluation Report (FITER) will be an acceptable alternative if you are only able to obtain two references. If you are currently enrolled in a clinical fellowship outside Ontario, one of three reference forms can be completed by your Program Director. Instruct your referees to send their completed reference forms directly to the College.

If your program does not issue FITERs (i.e. some family medicine programs), please provide a photocopy of an equivalent document or arrange for a detailed report from your program director to be sent directly to the College commenting on your attendance, performance and professional conduct in all rotations. The report must also indicate the date you have successfully completed your residency training program.

Return with your application your “List of Referees” using the enclosed form. If you are unable to arrange for references as specified above, please provide an explanatory letter.

22) Inquiry Form for Board Action Search by the Federation of State Medical Boards

If you have practised medicine or taken postgraduate medical training in the United States, a “Board action search” by the Federation of State Medical Boards of the United States is required. You must complete an “Inquiry Form: Federation of State Medical Boards Action Data Bank” form provided by the College and send it directly to the Federation of State Medical Boards at the address indicated in the form. The Federation will in turn send the Inquiry form directly to the College. You may fax the Inquiry


form to the Federation at (817) 868-4099.

IMPORTANT NOTES Translations All documents and letters not written in the English or French language must be accompanied by certified English or French translations. All translations must be certified by one of the following:

(i) A Certified Member of the Association of Translators and Interpreters of Ontario (ATIO). To find a certified translator, please visit their website: www.atio.on.ca. Translations completed by a certified member of the equivalent Association of Translators and Interpreters in another Canadian province/territory are also acceptable.

(ii) A Canadian Embassy overseas or a foreign embassy or consular office in Canada authorized to certify translations. Translations sent by the medical school are acceptable provided they are dated and stamped by the medical school to verify the contents and are received directly from the medical school with the original language document. Translations not meeting the above requirements are not acceptable.

Acceptable Medical School For the purpose of application for a certificate of registration in Ontario, a graduate from an acceptable unaccredited medical school means a person holding an M.D. or equivalent basic degree in medicine, based upon successful completion of a conventional undergraduate program of education in allopathic medicine that:

(i) teaches medical principles, knowledge and skills similar to those taught in undergraduate programs of medical education at accredited medical schools in Canada or the United States of America,

(ii) includes at least 130 weeks of instruction over a minimum of thirty-six months, and (iii) was, at the time of graduation, listed in the World Directory of Medical Schools published by the World Health Organization.

Requirements Subject to Change The registration requirements are subject to change without notice. Applicants must meet all current requirements. Inquiries concerning changes to the regulation should be directed to the Applications and Credentials Department. It is an offence under the Regulated Health Professions Act for a person to practise medicine in Ontario until such time as an appropriate certificate of registration has been issued.

Explanation of Application Fee

The application fee includes Ontario Fairness Commissioner Registration Audit Recovery fee of $5.

Professional Liability Protection – Exemption Provisions Under 51(6) of the College by-law, the requirement for professional liability protection does not apply to members who,

(i) provide acceptable written evidence they are not providing any medical services to any person in Ontario, or (ii) provide acceptable written evidence from their employer that they are only providing medical services to other employees and any

liability claim against the members will be covered by their employer. Applicants who qualify under either of these exemption provisions must telephone the College to discuss their case.

Confidentiality The College preserves secrecy with respect to all information it receives in connection with applications for registration, except in accordance with the following provisions in s. 36 of the Regulated Health Professions Act (Ontario):

(a) to the extent that the information is available to the public under this Act, a health profession Act or the Drug and Pharmacies Regulation Act;

(b) in connection with the administration of this Act, a health profession Act or the Drug and Pharmacies Regulation Act, including, without limiting the generality of this, in connection with anything relating to the registration of members, complaints about members, allegations of members’ incapacity, incompetence or acts of professional misconduct or the governing of the profession;

(c) to a body that governs a profession inside or outside of Ontario; (d) as may be required for the administration of the Drug Interchangeability and Dispensing Fee Act, the Healing Arts Radiation

Protection Act, the Health Insurance Act, the Independent Health Facilities Act, the Laboratory and Specimen Collection Centre Licensing Act, the Ontario Drug Benefit Act, the Coroners Act, the Controlled Drugs and Substances Act (Canada) and the Food and Drugs Act (Canada);

(e) to a police officer to aid an investigation undertaken with a view to a law enforcement proceeding or from which a law enforcement proceeding is likely to result;

(f) to the counsel of the person who is required to keep the information confidential under this section; (g) to confirm whether the College is investigating a member, if there is a compelling public interest in the disclosure of that information; (h) where disclosure of the information is required by an Act of the Legislature or an Act of Parliament; (i) if there are reasonable grounds to believe that the disclosure is necessary for the purpose of eliminating or reducing a significant risk

of serious bodily harm to a person or group of persons; or (j) with the written consent of the person to whom the information relates. 2007, c. 10, Sched. M, s. 7 (1).


Pathway 4 REQUIREMENTS CHECKLIST This checklist summarizes the schedule of requirements and is provided as an aid to organizing your application. Ensure that you follow the instructions in the schedule when completing each requirement.

Part A: Requirements to be submitted with your Application

1. Application Form Ensure all questions are answered and declaration on last page is properly completed.

2. Medical Degree from an Acceptable Medical School Photocopy of your medical degree.

3. Current Practice Description and Ontario Practice Plans Complete the College form for this purpose.

4. Independent or Full Unrestricted Licence in the USA or Canada (or proof of eligibility) Photocopy of current independent or full medical licence without restrictions in USA or Canada.

5. Consent to Disclosure of Criminal Record Information Option A: Arrange your own CPIC check. Option B: Complete consent form and return with copy of two pieces government-issued valid ID and fee.

6. Canadian Citizenship, Permanent Resident Status, or Work Permit Copy of Canadian birth certificate or passport, PR card with date of birth shown or valid work permit.

7. Passport (if applicable) Notarized copy of current passport required only if you are not Canadian citizen or permanent resident.

8. Evidence of Name Change (if applicable)

9. Declaration for Breaks in Training or Practice History Explain any breaks of six or more months in your training or practice history using CPSO form.

10. Professional Liability Protection Complete Undertaking or Declaration form.

11. Report from NPDB and HIPDB Data Banks If you have practised or trained in the USA, obtain NPDB & HIPDB report.

12. MINC Consent Form Sign and return MINC Consent form to enable issuance of (or verification of existing) MINC number.

13. Curriculum Vitae Curriculum vitae must list all qualifications; dates/locations of all training and practice appointments.

14. Payment of Fees Application fee must be enclosed with your application. Personal cheques not accepted.

Part B: Requirements to be sent to College by Source Organization

15. Medical School Transcript Arrange for your medical school to send official academic transcript directly to CPSO.

16. USMLE or an Acceptable Alternative Arrange for official pass results to be sent directly to College from examining body.

17. Letter from Supervisor Arrange for letter outlining proposed practice and supervision arrangement to be sent directly to College from supervisor.

18. Evidence of Completion of Accredited Residency in USA Arrange for residency training report to be sent directly to College from your residency program.

19. Certification as a Specialist by a US Specialty Board Arrange for evidence of your current specialty certification to be sent directly to College by specialty Board.

20. Evidence of Standing and Independent Practice Licence Send CPSO form to licensing authority in every jurisdiction where you have practised or trained.

21. Reference Forms Send the College reference forms for completion to chief of staff, department head and chief nurse.

22. Inquiry Form for Board Action Search by the Federation of State Medical Boards (FSMB) If you have practised or trained in the USA, send Board Action Inquiry form to FSMB.

Page 1 of 2

REGISTRATION COMMITTEE: PROCESSING TIMES AND MEETING DATES The Registration Committee normally meets once every 4 to 6 weeks. Meeting dates for 2012/2013 and corresponding deadlines are shown below.

Applications

All incoming applications must undergo initial assessment by the Applications and Credentials Department. Applications must be assessed and all credentialing documents received by the Applications and Credentials Department before referral to the Registration Committee. This initial assessment can take up to five weeks given that on average, 100 cases are referred to the Registration Committee each month.

Applications that include open and past complaints, legal matters, breaks in practice, supervision, any issues pertaining to section 2 (1) of Ontario Regulation 865/93: Registration, and any questions that are answered with “Yes” responses will require additional documentation after the initial assessment to clarify these matters. This will increase the processing time by 5 to 7 weeks at a minimum, depending on the nature of the outstanding requirements. Additional requirements based on individual applications may be requested to facilitate the committee’s decision.

Co-ordinator

The Co-ordinator will ensure that your case is brought forward with sufficient information to make a decision. He or she will produce a legal file on your behalf, including the copying, scanning, collating and pagination of files. The legal file is submitted to the Registration Committee, which is comprised of practising members of the profession. The Registration Committee reviews all cases 2 weeks prior to the meeting date. Applications that do not fall within the published deadlines (see below) cannot be accommodated.

Meeting Dates

Tentative meeting dates corresponding to receipt of your application will be indicated by your co-ordinator and posted to your online application status account once the initial assessment is complete. Please do not schedule a practice start date until you receive the outcome of your review – doing so will not speed up the process.

Decision Letters

Decision letters are sent electronically and by hard copy within 5 to 7 business days after the meeting. Once final documents are received, a quality check requiring three individual reviews is performed and your certificate of registration is issued within 3 business days.

Every effort is made on the part of the College to meet the deadlines for the corresponding meeting dates. Nevertheless, these deadlines are not binding on the College and there is no guarantee with respect to scheduling a Registration Committee review. Complex applications requiring more staff preparation time, including those where conduct-related issues have been identified, must often be scheduled for a subsequent meeting date. Registration Committee caseload limitations may also force deferral of an application to a subsequent meeting date.

We encourage you to arrange for the submission of requirements in a timely fashion, as the process is dependent on you to facilitate the review of your application.

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Interim Meetings

Unscheduled interim meetings of the Registration Committee may occasionally occur between regularly scheduled meetings for review of eligible registration policy-based applications. Such meetings are held subject to time of year, overall Registration Committee caseload, and availability of a committee member quorum. Applicants scheduled for review at these meetings will be notified accordingly.

Meeting Dates: 2012/2013 Credentialing Completion Deadlines

To enable referral to the Registration Committee, all credentialing and supporting documents must be received and assessed by these dates. Should you miss a confirmed deadline, you will be working with the next meeting date deadlines.

APPLICATION RECEIVED BY INITIAL ASSESSMENT FINAL DOCUMENTS

ASSESSED BY MEETING DATE

June 21, 2012 July 26, 2012 August 9, 2012 September 13, 2012

July 26, 2012 August 30, 2012 September 13, 2012 October 18, 2012

August 23, 2012 September 27, 2012 October 11, 2012 November 15, 2012

September 20, 2012 October 25, 2012 November 8, 2012 December 13, 2012

November 15, 2012 December 20, 2012 January 3, 2013 February 7, 2013

December 20, 2012 January 24, 2013 February 7, 2013 March 7, 2013

January 24, 2013 February 28, 2013 March 14, 2013 April 18, 2013

February 28, 2013 March 28, 2013 April 11, 2013 May 16, 2013

March 28, 2013 May 2, 2013 May 16, 2013 June 20, 2013

May 9, 2013 June 13, 2013 June 27, 2013 August 1, 2013

June 20, 2013 July 25, 2013 August 8, 2013 September 12, 2013

July 25, 2013 August 29, 2013 September 12, 2013 October 17, 2013

August 22, 2013 September 26, 2013 October 10, 2013 November 14, 2013

September 19, 2013 October 24, 2013 November 7, 2013 December 12, 2013

Decision letters are sent electronically and by hard copy within 5 to 7 business days after the meeting. Once final documents are received, a quality check requiring three individual reviews is performed and your certificate of registration is issued within 3 business days.

Pathway 4 CURRENT PRACTICE DESCRIPTION & ONTARIO PRACTICE PLANS Completion of this form is required as part of the application requirements under Pathway 4 of the College’s registration policy, “Alternative Pathways to Registration.” It must be completed together with all other requirements under Pathway 4.

This form will assist the College in determining whether you meet the Pathway 4 pre-requsite that you currently hold, or be eligible to apply for, an independent or full licence or certificate to practise without restrictions in the USA.

It will also assist in determining whether the nature of your present practice outside Ontario and your intended practice in this province present any concerns with respect to change of scope, continuity and recency of practice.

COMPLIANCE WITH INDEPENDENT PRACTICE REQUIREMENT

A. Current Independent Licensure and Practice Location

(1) Do you currently hold in a state in the USA an independent or full licence, or certificate of registration without restrictions? (If “Yes” skip question 2.)

Yes □ No □ Name the state(s) where you hold this type of licence or certificate: ________________________________________________________________

(2) If you answered “No” to question (1), are you currently eligible to apply for an independent or full licence or certificate to practise without restrictions in a state in the USA?

Yes □ No □ Name the state where you are currently eligible to apply for this type of licence or certificate: _________________________________________________________________

Note: If you have answered “no” to both questions (1) and (2), you will not meet the Pathway 4 pre-requisite that you currently hold, or be eligible to apply for, an independent or full licence or certificate to practise without restrictions in the USA. Please provide an explanation.

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CURRENT INDEPENDENT PRACTICE DESCRIPTION (if applicable)

B. Practice Location and Frequency

a) In a typical work week, how many hours do you spend in practice and ancillary professional activities?

________________

b) Complete the table below to describe your current practice during a typical work week:

Facility Check ones that best

describe your PRESENT practice

Number of hours in direct patient contact

Number of patients seen

Office Practice Private Office Health Service Organization Community Health Centre Family Health Network Walk-in Clinic; After hrs, Urgent Care (e.g., generally no appointments; generally episodic care, non-static patient base)

Academic Family Practice Unit Locum Hospital Community Hospital

> Inpatients

> Outpatients

> Emergency

> Surgical Assist

> Day Surgery

> Hospitalist

Academic/Teaching Hospital

> Inpatients

> Outpatients

> Emergency

> Surgical Assist

> Day Surgery

> Hospitalist

Long-term Care Facility/Nursing Home etc. Independent Health Facility (IHF)/Diagnostic or Procedural Out of Hospital Facilities (Non-IHF)

Government Facility (jail, army, etc.)

House Call Service

Other (specify)_____________________________________ …/3

3 of 5 C. Clinical Activity

Please describe your practice using the table of practice descriptor codes listed in the table in the appendix. We would like you to reflect on your actual practice (i.e. “what you do”), rather than the certification(s) you may hold. If you list more than one code, please estimate the percentage of time you spend in each area.

Code # (3 digits) Practice Type 0-10% 10-20% 20-40% 40-60% 60-80% 80% + a)

b)

c)

d)

e)

f) Other:

D. Most Common/Diseases/Procedures

Please list the 5 most common Conditions/Diseases/Procedures that you see/do in your practice:

1.

2.

3.

4.

5.

E. Continuing Professional Development

Please provide information about the type of professional development activities in which you participated in the past 12 months and the amount of time spent within each activity.

a) Regardless of your certification or membership status with the RCPSC or the CFPC do you voluntarily fulfill their professional development requirements?

Yes □ No □ Not Sure □

b) Estimate how many hours you spent in the following formal CME activities in the past 12 months:

0 - 10hrs 10 - 25hrs 25 -50hrs 50+hrs

RCPSC/CCFP accredited courses, conferences and workshops □ □ □ □

Internet based CME Activities (e.g. on-line journals, Guidelines, etc.) □ □ □ □ Practice-based small group sessions □ □ □ □ Self-directed learning programs □ □ □ □ Hospital committees □ □ □ □ Hospital educational rounds □ □ □ □ Reading journals □ □ □ □ Other courses, conferences and workshops □ □ □ □ Other ________________________________________________________________________________________________ _____________________________________________________________________________________________________

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ONTARIO PRACTICE PLANS

F. Details of Ontario Practice Plans

(1) Do you intend to engage in the same type of practice in Ontario as in your current practice described in parts B to E above?

Yes □ No □ If “No,” explain how your planned practice in Ontario will differ from your current practice: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

(2) When do you intend to begin practising in Ontario? __________________________________________

(3) How long do you expect to practise in Ontario? 1 - 2 years □ 2 - 5 years □ 5 or more years □

SIGNATURE

Full Name of Applicant: _____________________________________________________________________

I certify that the information provided in this form is true, complete and accurate:

______________________________ ______________________________ Signature Date

Please return completed form with your application for registration to the following:

Registration Department College of Physicians and Surgeons of Ontario 80 College Street

Toronto, ON M5G 2E2 Fax: (416) 967-2623

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APPENDIX: Table of Practice Descriptors (to be used for Question C)

ANAESTHESIA OBSTETRICS & GYNAECOLOGY 809 Neurosurgery 101 Anaesthesia 501 Gynaecologic Oncology 810 Ophthalmology

102 Chronic Pain Management without general/spinal anaesthesia 502 Gynaecologic Reproductive

Endocrinology & Fertility 811 Orthopaedic Surgery

GENERAL/FAMILY PRACTICE 503 Gynaecologic Surgery and prenatal care 812 Otolaryngology

201 General/Family Practice with active/admitting hospital privileges 504 Office Gynaecology 813 Plastic Surgery

202 General/Family practice without hospital privileges 505 Obstetrical Practice limited to prenatal

care 814 Surgical Practice without operative treatment

MEDICINE 506 Obstetrics 815 Thoracic Surgery 301 Allergy 507 Urogynaecology 816 Urology 302 Cardiology 508 Sexual Counselling 817 Vascular Surgery 303 Clinical Immunology PAEDIATRICS 818 Transplant Surgery 304 Clinical Pharmacology 601 Neonatology 819 Endoscopy 305 Critical Care Medicine 602 Paediatrics OTHER 306 Dermatology 603 Paediatric Cardiology 901 Acupuncture 307 Emergency Medicine 604 Paediatric Nephrology 902 Administrative Medicine 308 Endocrinology 605 Paediatric Neurology 903 Community Medicine (Public Health) 309 Gastroenterology 606 Paediatric Surgery 904 Palliative Care 310 Genetics 607 Paediatric Allergy/Clinical Immunology 905 Psychotherapy 311 Geriatric Medicine/Nursing Homes 608 Paediatric Oncology 906 Sport Medicine 312 Haematology 609 Paediatric Orthopaedics 907 Clinical Fellow-without moonlighting 313 Infectious Diseases 610 Paediatric Gastroenterology 908 Clinical Fellow-with moonlighting 314 Internal Medicine 611 Paediatric Haematology 910 Child and Adolescent Psychiatry 315 Medical Oncology 612 Paediatric Haematology/Oncology 911 Substance Abuse 316 Nephrology 613 Paediatric Infectious Diseases 912 Aviation Medicine 317 Neurology 614 Paediatric Respiratory Medicine 913 Hyperbaric/Diving Medicine 318 Nuclear Medicine RADIOLOGY 914 Sleep Medicine 319 Occupational Medicine 701 Diagnostic Imaging 915 Complementary Medicine

320 Physical Medicine and Rehabilitation 702 Therapeutic Radiology/Radiation Oncology 916 Long Term Care

321 Psychiatry 703 MRI 917 Urgent Care/Walk-in Clinics 322 Respiratory Medicine 704 CT (computed tomography) 918 EEG 323 Rheumatology SURGERY 919 EMG LABORATORY MEDICINE 801 Laser Surgery 920 Spirometry 401 Medical Biochemistry 802 Assistance at Surgery 921 House Calls 402 Medical Microbiology 803 Cardiovascular Surgery 922 Sclerotherapy 403 Pathology-Anatomic 804 Clinical Associates-Surgical 923 Hypnotherapy 404 Pathology-General 805 Colorectal Surgery 924 Teaching 405 Pathology-Haematological 806 Cosmetic Surgery 925 Research

406 Pathology-Neurological 807 General Surgery 926 Administration (in Medical schools, hospitals, etc.)

808 General Surgical Oncology 927 Other Professional Activities i.e. College Activities

CPSO Registration Department 11/08

Criminal Record Check: Instructions A criminal record check using the Canadian Police Information Centre (CPIC) database is required. The check must cover convictions and current charges. To complete this requirement, choose one of the following two options:

Option A: Make your own arrangements to obtain a valid CPIC check from a municipal or provincial

police service in Canada. Do not use a third-party commercial online vendor.

Option A is strongly recommended, especially if you have an urgent starting date.

Option B: Submit the enclosed consent form. For a fee, the College will obtain a CPIC check on your behalf from the Ontario Provincial Police (OPP). Allow for at least 15 business days processing time. Applicants from outside Canada must use this option.

If your check indicates a possible match in the CPIC system, fingerprint verification from the Royal Canadian Mounted Police (RCMP) will be required to complete the process. You will be notified if this applies to you.

Option A – Additional Instructions: Submit to the College a valid clearance letter or certificate from a municipal or provincial police service in

Canada (as listed in the CPIC National Directory at www.cpic-cipc.ca).

A “vulnerable persons” check is not required, but be sure that your CPIC check covers convictions and current charges – both are required. Please check this with the police service. Some (e.g. London police service) do not include current charges in their basic CPIC check, in which case you must ask for a vulnerable persons check or use a different police service.

Original is required. Must be on police letterhead and contain original signature(s) and date of issuance.

CPIC results are valid for six months from date of issue and must be updated if necessary.

You are responsible for any fee charged by the police service. The College cannot reimburse this fee.

Some municipal police services will conduct checks only for local residents. If necessary, refer to the CPIC National Directory to locate a Canadian police service that will conduct your check.

Online Checks by Commercial Vendors are NOT accepted!

Option B – Additional Instructions: Complete and return to the College the attached Consent and Authorization form.

Enclose photocopies of 2 pieces of government identification (e.g. valid driver’s licence, current passport, national card). If using a card, please provide photocopy of the front and back. Note that health cards and social insurance cards are not acceptable. Your name and date of birth must be legible. You may wish to enlarge the photocopies as needed.

Make certain your name and date of birth information in the consent form is accurate. Any omissions or discrepancies will require returning the form to you for correction. All name variations must be included on your form (maiden name, official name changes, or alternate spellings).

Once signed and dated, the consent is valid for 1 month only. Return completed form immediately.

The OPP requires a minimum of 15 business days to complete the check. The College can neither expedite this check nor process your application without it. Results are valid for six months.

Rev. March 21, 2012

CRIMINAL RECORD INFORMATION AUTHORIZATION FORM

The purpose of the criminal record check is to further the objects of the College of Physicians and Surgeons of Ontario as set out in section 3(1) of the Health Professions Procedural Code. Surname

Given Name Middle Name(s) Date of Birth yyyy mm dd

Maiden Name or Other Names used (if applicable)(all legal names in lifetime) Gender Male Female

Current Mailing Address (number, street, apt, lot, concession, township, rural route #, city, postal code) S.I.N. not necessary Professional Position and Location Physician CONSENT I hereby consent to the disclosure of my clean record or my criminal convictions for which a pardon has not been granted, records of discharges which have not been removed from the CPIC system in accordance with the Criminal Records Act, and records of outstanding criminal charges of which the OPP is aware to the following persons: The College of Physicians and Surgeons of Ontario.

FINGERPRINT VERIFICATION If I deny that I am the offender with the criminal record so provided, I may present myself to the police in my jurisdiction to determine whether my fingerprints match those associated with the criminal record. No other defence is afforded me, but, if I am a physician, I will have a hearing at the College before my certificate of practice is denied, restricted or removed. RELEASE I hereby release and forever discharge Her Majesty the Queen in right of Ontario, the OPP, the Commissioner of the Ontario Provincial Police and the College of Physicians and Surgeons and any or all of their respective members, directors, employees, servants, and agents, from any and all actions, claims and demands for damages, loss or injury howsoever arising which may hereafter be brought against them, jointly or severally, as a result of their participation in this criminal records check on me. _______________________________________ ________________________________ Signature Date MY INFORMATION CONTACT FOR QUESTIONS ABOUT MY CRIMINAL RECORD CHECK: Rocco Gerace, Registrar The College of Physicians and Surgeons Phone: 416-967-2617

DECLARATION: To Account for Breaks in Training or Practice History I

nstructions to Applicant: Use this form to declare and account for all periods, since your

graduation from medical school, during which you did not practise medicine either as a postgraduate clinical trainee or as a clinical practitioner in any capacity (observerships and research appointments included).

Declare only those periods of six continuous months or more. Once completed, enclose with application form and return to the

College’s Registration Department. Do not return form if you have no breaks to declare.

Applicant’s Declaration: I declare that after I graduated from medical school, I ceased practising medicine for six continuous months or more on the following occasions:

Dates Reason for Break (mo./yr. to mo./yr.) (explain why you took a break, e.g. maternity leave, vacation, immigration;

attach additional pages as necessary) ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ I make this declaration conscientiously believing it to be true, and knowing that it is of the same legal force and effect as if made under oath. _________________________ _________________________ ___________________ Applicant’s Signature Print Name Date Rev. Jan/11

Declaration by Applicant: Professional Liability Protection Under the College’s registration regulation, applicants for registration must have professional liability protection in compliance with the College’s by-laws. Applicants are required to sign a declaration that they comply with s. 50.2 of the by-law, as follows:

Each member shall obtain and maintain professional liability protection that extends to all areas of the member’s practice, through one or more of,

(a) membership in the Canadian Medical Protective Association; (b) a policy of professional liability insurance issued by a company licensed to carry on business in

Ontario that provides coverage of at least $10,000,000; (c) coverage under the Treasury Board Policy on Legal Assistance and Indemnification (for Crown

servants of Canada). Complete and return this Declaration to the College as evidence of your professional liability protection. This form must be signed, dated and returned to the College no more than six months in advance of expected date of registration. An incomplete or outdated form will not be accepted. Mail or fax completed form to: Registration Department

College of Physicians and Surgeons of Ontario 80 College Street, Toronto, ON, Canada M5G 2E2 Fax: (416) 967-2623 IMPORTANT! Do not complete this form if you do not yet have professional liability protection

and are applying to the Canadian Medical Protective Association. Instead, complete the form “Undertaking by Applicant: Professional Liability Protection.”

See over for Declaration…

Page 1 of 2

Declaration by Applicant: Professional Liability Protection I, ______________________________________________________________________, hereby declare Full name of person applying for College registration to the College of Physicians and Surgeons of Ontario (“the College”) as follows: 1. I currently have professional liability protection that extends to all areas of my practice in Ontario. 2. My professional liability protection is provided through:

□ a) membership in the Canadian Medical Protective Association (“CMPA”), under membership no.: _______________________, or

□ b) a policy of professional liability insurance issued by a company licensed to carry on business in Ontario that provides coverage of at least $10,000,000, namely

______________________________________________________________________, or name of company and your policy number

□ c) coverage under the Treasury Board Policy on Legal Assistance and Indemnification (for Crown servants of Canada).

3. I understand that after I am registered with the College and have identified the provider of my

professional liability protection, the College may inquire with the provider regarding whether I have professional liability protection in compliance with s. 50.2 of the College by-law, and I hereby consent to disclosure of this information to the College by the provider of my professional liability protection.

4. I understand that I must have available in my office, in written or electronic form, for inspection by

the College, evidence that I have professional liability protection. 5. I understand that my registration with the College will expire when I no longer have professional

liability protection. 6. I understand that before each annual renewal of my College registration, I must sign a declaration that

I have professional liability protection.

7. I understand that it is an offence under s. 92 of the Health Professions Procedural Code to make a false representation for the purpose of having a certificate of registration issued.

8. I understand that I will be deemed not to have satisfied the requirements and qualifications for

a certificate of registration if I have made a false or misleading representation in this Declaration. ____________________________________________ ______________________________

Signature of applicant Date _______________________________________________________ _____________________________________ Print name of applicant College reference number (if known)

Mail or fax this completed form to: Registration Department College of Physicians and Surgeons of Ontario 80 College Street, Toronto, ON, Canada M5G 2E2 Fax: (416) 967-2623

Note: Incomplete forms cannot be accepted and will be returned. CPSO Registration Dept. – April/09

Undertaking by Applicant: Professional Liability Protection Under the College’s registration regulation, applicants for registration must have professional liability protection in compliance with the College’s by-laws, as follows:

Each member shall obtain and maintain professional liability protection that extends to all areas of the member’s practice, through one or more of,

(a) membership in the Canadian Medical Protective Association; (b) a policy of professional liability insurance issued by a company licensed to carry on business in

Ontario that provides coverage of at least $10,000,000; (c) coverage under the Treasury Board Policy on Legal Assistance and Indemnification (for Crown

servants of Canada). This Undertaking must be completed if you do not yet have professional liability protection in Ontario and need to be registered with the College in order to qualify for professional liability protection. For example, if you are applying to the Canadian Medical Protective Association for the first time, you will need to complete this Undertaking. This form must be signed, dated and returned to the College no more than six months in advance of expected date of registration. An incomplete or outdated form will not be accepted. Mail or fax completed form to: Registration Department

College of Physicians and Surgeons of Ontario 80 College Street, Toronto, ON, Canada M5G 2E2 Fax: (416) 967-2623

Note: You will need to submit a Declaration to the College within 30 days of obtaining your

professional liability protection. A form for this purpose will be enclosed with your certificate of registration.

See over for Undertaking…

Page 1 of 2

Undertaking by Applicant: Professional Liability Protection I, ___________________________________________________________________, hereby undertake, Full name of person applying for College registration agree and consent to the College of Physicians and Surgeons of Ontario (“the College”) as follows: 1. Before I provide any medical service in Ontario to any person, I will obtain professional liability

protection that complies with s. 50.2 of the College by-law.

Specifically, my professional liability protection will extend to all areas of my practice and be provided through one or more of,

(a) membership in the Canadian Medical Protective Association (“CMPA”);

(b) a policy of professional liability insurance issued by a company licensed to carry on

business in Ontario that provides coverage of at least $10,000,000. (c) coverage under the Treasury Board Policy on Legal Assistance and Indemnification

(for Crown servants of Canada). 2. Within thirty (30) days of obtaining such professional liability protection, I will sign and submit to the

College a declaration to that effect, using the College form “Declaration by Member: Professional Liability Protection.”

3. I understand that after I am registered with the College and have identified the provider of my

professional liability protection, the College may inquire with the provider regarding whether I have professional liability protection, and I hereby consent to disclosure of this information to the College by the provider of my professional liability protection.

4. I understand that I must have available in my office, in written or electronic form, for inspection by the

College, evidence that I have professional liability protection. 5. I understand that my registration with the College will expire when I no longer have professional

liability protection. 6. I understand that before each annual renewal of my College registration, I must sign a declaration that

I have professional liability protection. 7. I understand that a breach of this undertaking is an act of professional misconduct which may result in

referral of a specified allegation against me of professional misconduct to the Discipline Committee of the College.

____________________________________________ ______________________________

Signature of applicant Date _______________________________________________________ _____________________________________ Print name of applicant College reference number (if known)

Mail or fax this completed form to: Registration Department College of Physicians and Surgeons of Ontario 80 College Street, Toronto, ON, Canada M5G 2E2 Fax: (416) 967-2623

Note: Incomplete forms cannot be accepted and will be returned.

Reg Dept April 2009

Consent for Release of Information to Medical Identification Number for Canada (MINC)

To receive your Medical Identification Number for Canada (MINC), you need to complete this consent. Please read the details about the MINC system and answer the question below. A not-for-profit corporation, Medical Identification Number for Canada, known as “MINC#NIMC”, has been incorporated by the Federation of Medical Regulatory Authorities of Canada (FMRAC) and the Medical Council of Canada (MCC) for the sole purpose of administering the MINC number system. This number will be issued to all health care professionals who consent in writing. Once assigned, an individual’s MINC number will remain unchanged throughout his/her entire medical career. Assigned numbers are never reused and individuals will carry the same number even if they leave Canada and return, move between jurisdictions or change registration status. The only information encoded in an individual’s MINC is a country code (CA for Canada) and a profession code (MD for Medicine). The MINC number does not imply any special privilege, rights or status; it is simply a series of letters and numbers for identification purposes. When you consent, the College of Physicians and Surgeons of Ontario will submit your personal information to MINC#NIMC as follows: name(s) (and previous name(s) if applicable), gender, date of birth, country of birth and year and university of graduation, collectively referred to as the “Core Information”. MINC#NIMC will use Core Information to either generate or confirm an existing MINC and will retain the Core Information and its associated MINC in its system for the purposes of identifying individuals and ongoing identity confirmation by Prime and Licensed Users of the MINC system. “Prime Users” are those organizations that are authorized to request issuance of a MINC (the MCC and the twelve Canadian medical regulatory authorities). “Licensed Users” are those organizations that have contracted with MINC#NIMC to use these numbers. Not-for-profit and public sector organizations that are involved in the education, certification, licensure or professional practices of physicians in Canada may apply to MINC#NIMC for a license to use the MINC system as a means of:

(i) Accurately identifying individuals with whom they have dealings, (ii) Processing information relating to those individuals, and (iii) Linking or exchanging physician information with other Licensed or Primary Users for Approved

Purposes such as the compilation of statistics, the development of profiles, the administration of programs or benefits, the management of the health system and research.

Licensed Users agree to comply with MINC#NIMC’s Privacy Code, with privacy, security and confidentiality provisions, and with applicable privacy legislation as part of their licensing agreements. The only information that shall be disclosed to Licensed Users shall be the medical identification numbers for their own members. Prime Users will have controlled access to both the MINC number and Core Information to facilitate the performance of their regulatory responsibilities. For a more complete description of MINC#NIMC, including its Privacy Code and a complete list of all Prime and Licensed Users and their approved uses, consult the MINC#NIMC website at www.minc-nimc.ca. Consent I have read and understand the above information, and consent to the College of Physicians and Surgeons of Ontario’s release of the Core Information to MINC#NIMC for the purpose of generating a MINC number that will be permanently assigned to me or checking my existing Core Information with MINC#NIMC. I further consent to MINC#NIMC storing the MINC number in its database and disclosing the MINC number to Prime and Licensed Users, as outlined above. I also understand that I may withdraw my consent to MINC at any time, by written notice to MINC#NIMC.

Yes □ No □

__________________________________ __________________________________ _________________

Print Full Name Signature Date CPSO Registration or Reference Number (if known): _____________

April 9, 2010

http://www.minc-nimc.ca/

READ INSTRUCTIONS CAREFULLY: DO NOT SEND INCOMPLETE FORM BACK TO THIS COLLEGE. IT IS YOUR RESPONSIBILITY TO HAVE THIS FORM COMPLETED BY ALL MEDICAL LICENSING AUTHORITIES WHERE YOU HAVE BEEN REGISTERED. INFORMATION PROVIDED ON THIS FORM IS VALID FOR SIX MONTHS ONLY. UPDATED INFORMATION WILL BE REQUIRED IF YOUR CERTIFICATE OF REGISTRATION IS NOT ISSUED WITHIN THAT PERIOD.

CONFIRMATION OF STANDING by Medical Licensing Authority

Consent to Release Information

to the College of Physicians and Surgeons of Ontario

- This section to be completed by the Applicant - To the Medical Licensing Authority in: __________________________________________________________ (province, state, territory or country) I am applying for a certificate of registration to practise medicine in the province of Ontario, Canada, and before my application can be assessed, information relating to my qualifications and medical practice activities in your jurisdiction is required. I hereby authorize your releasing to the College of Physicians and Surgeons of Ontario all information requested below and any other information respecting me which you deem relevant to my present application for a certificate of registration to practise medicine in Ontario, Canada. I request the completed form and any appended information to be forwarded directly to:

The College of Physicians and Surgeons of Ontario Registration Department 80 College Street Toronto, Ontario, Canada M5G 2E2

I understand you may require a fee for this service. _______________________________________ Full Name of Applicant (Print or Type) _______________________________________ Signature of Applicant _______________________________________ _______________________________________ _______________________________________ _______________________________________ Applicant’s Address

_______________________________________ Licence Number _______________________________________ Date *Note to Applicant: A completed form is required from the medical licensing authority in every jurisdiction where you have practised medicine, postgraduate training appointments included. Photocopy this form if you need additional copies.

Page 1 of 3

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- This section to be completed by the Medical Licensing Authority - 1. This is to verify that,

Dr.________________ ________________________________________________________ Full Name of Applicant a) Graduated From: _________________________________________________________ Name of Medical School

b) Has been issued the following licence(s) by this medical licensing authority:

Type of Licence Licence Number Date Issued Date Expired or Cancelled month / year month / year

/ / / / / / / / c) Has the following specialty qualification(s) which is recognized by this medical licensing

authority: Specialty Granted By Date

month / year ________________________ ________________________ ___________/____________

________________________ ________________________ ___________/____________

________________________ ________________________ ___________/____________

d) Undertook the following postgraduate training appointment(s) in the jurisdiction governed

by this medical licensing authority: Type of Program Hospital/University From/To month / year

________________________ ________________________ ___________/____________

________________________ ________________________ ___________/____________

________________________ ________________________ ___________/____________

3 of 3

2. Has the above-named physician ever been the subject of an inquiry or an investigation by this

licensing authority involving an allegation of professional misconduct, incompetence, incapacity or any like allegation?

Yes No

3. Is the above-named physician currently the subject of an inquiry or investigation by this licensing

authority involving an allegation of professional misconduct, incompetence, incapacity or any like allegation?

Yes No

4. Does the above-named physician appear in the records of this licensing authority as having been

subject to reduced, suspended or cancelled privileges by a hospital due to incompetence, negligence, incapacity or any form of professional misconduct?

Yes No

5. Have there ever been any disciplinary or fitness to practise findings, or any like findings, made by

this licensing authority against the above-named physician?

Yes No

If “yes” has been answered to question 2, 3, 4 or 5 please provide all relevant information and documentation. Name and Title of Official for Medical Licensing Authority Name of Medical Licensing Authority Signature of Medical Licensing Authority Official Date Mailing Address Email Address Telephone Number

Seal or Stamp of Medical Licensing

Authority to be Affixed Here

Fax Number *Note to the Licensing Authority: You may fax the completed form to the Registration Department, College of Physicians and Surgeons of Ontario. Please ensure the original is mailed promptly.

Rev. July 2008

REFERENCE FORM Name of Applicant: ___________________________________________________________________ Referee: Name and Position _______________________________________________________________

Hospital Name/Location __________________________________________________________ This evaluation should be based on demonstrated performance compared to that reasonably expected of a physician with similar level of training, experience and background as the applicant. Please complete all parts of this form. Referee Information:

i. Is the applicant related to you? Yes No

ii. Are you in a position of formal authority over the applicant’s work? Yes No

iii. In what capacity have you worked with the applicant? (i.e. Chief of Staff, Program Director, Colleague, Nurse, etc.) _________________________________________________________________________

iv. How long have you worked with the applicant? _____________________________________________

v. Where have you worked with the applicant? _______________________________________________ Candidate Information:

I. Clinical Practice

Description of the candidate’s medical activities: ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Superior Fully Satisfactory Satisfactory Not Satisfactory Unknown Clinical knowledge

Clinical competence

Professional judgment

Technical skills

Problem solving ability

Discharge planning

Overall performance

Comments:________________________________________________________________________________

_________________________________________________________________________________________

Page 1 of 3

II. Resource Utilization, and Administrative Duties

Above Average Average Below Average Utilization of diagnostic and therapeutic agents

Timeliness of medical record completion

Quality of medical record documentation

Prepares written documentation (e.g. patient notes, discharge summaries and patient letters) that are accurate, organized and timely

On-call dependability

Participates in administration and leadership roles, as appropriate

Attendance at meetings/Committee participation

Comments:________________________________________________________________________________

_________________________________________________________________________________________

III. Professional Attitude / Interpersonal Skills

Above Average Average Below Average Oral communication skills

Participate effectively and appropriately in an interprofessional health care team

Establishes a therapeutic relationship and communicates well with patients and families

Relationship with other physicians

Relationship with nursing staff

Demonstrates integrity, honesty, compassion and respect for others

Professional behavior (attitude/emotional stability)

Comments:________________________________________________________________________________

_________________________________________________________________________________________

IV. Continuing Professional Development

Above Average Average Below Average Unknown Participation in educational activities

Demonstrates lifelong learning skills

Aware of own limitations; seeks assistance and/or feedback; and accepts advice graciously

Comments: _______________________________________________________________________________ _________________________________________________________________________________________

Page 2 of 3

Page 3 of 3

V. Strengths/Areas of Improvement

What are the applicant’s greatest strengths?

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

What areas of improvement and development have been identified for the applicant? _________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

VI. Have you any additional information with respect to this applicant which may be relevant to his/her

application for registration to practice medicine in Ontario? _________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

VII. Summary Recommendation (Please choose the most appropriate statement)

Recommend without reservation

Recommend with reservations (please explain below)

Do not recommend (please explain below)

Please call me to discuss this applicant Yes No

Phone number and the best time to contact you: _________________________________________

Comments/Reservations: _________________________________________________________________________________________

_________________________________________________________________________________________

Print Name: _________________________________ Title: ________________________________ Signature: _________________________________ Date: ________________________________ Please mail completed form directly to the College, not to the applicant: Registration Department College of Physicians and Surgeons of Ontario 80 College Street

Toronto, ON M5G 2E2 Completed form may also be faxed to the Registration Department at (416) 967-2623. If faxing, be sure to include a covering page clearly indicating the source. If you have any questions, please contact the Inquires Section in the Registration Department at (416) 967-2617. Thank you. We appreciate the time you took to complete this document.

Rev. Nov. 1, 2011

LIST OF REFEREES

This form is to be completed by applicants who are required to arrange for references. Please list below the names of the three referees to whom you have sent the College’s Reference Form for completion.

Three references are required from the hospital where you now practice: 1. Chief of Staff 2. Department Head 3. Chief Nurse

If your current practice is not hospital-based, arrange for three references from physicians in authority who can comment on your current practice, e.g. head of staff or most senior physician at your clinic.

If you are currently completing your residency training in Canada, in lieu of the reference forms please arrange for a copy of your final in-training evaluation report (FITER) to be sent directly from your Program Director to the College.

This list will assist the College in efficient credentialing of your application. Return this form with your application. Applicant’s Full Name: _________________________________________ Date: _______________________ APPLICANT’S REFEREES: (1) Referee: Name _______________________________________________________________________

Position _____________________________________________________________________

Hospital Name _______________________________________________________________

Location (municipality, province/state) ________________________________________ (2) Referee: Name _______________________________________________________________________

Position _____________________________________________________________________

Hospital Name _______________________________________________________________

Location (municipality, province/state) ________________________________________

(3) Referee: Name _______________________________________________________________________

Position _____________________________________________________________________

Hospital Name________________________________________________________________

Location (municipality, province/state)________________________________________

CPSO Reg Dept. April /10

For Office Use Only

Credit Card Payment Authorization Form for Registration Fees Please complete this online form, print out and add your signature for your credit card payment. Submission Options: (See instructions below. To avoid duplicate charge, please only submit once)

Address

City Province/State

Country

Date CPSO#/File#

CPSO#/File#

Email

First Name

Middle name

Postal/Zip Code

Application Fee – Postgraduate Education $158

Membership Fee – Postgraduate Education $306

Application Fee – Independent Practice and all other classes $770

Membership Fee – Independent Practice and all other classes $1,530

Application Fee – Short Duration class $311

Criminal Record Check Processing Fee $15

Other item: Amount:

TOTAL

* Expiry date (MM/YY)

Card number

Cardholder signature Please print out this form and sign above.

Visa MasterCard American Express

I authorize the College of Physicians and Surgeons of Ontario to charge:

to my credit card (check one)

Mail OR fax this form (but DO NOT do both to avoid possible overcharge) to: College of Physicians and Surgeons of Ontario 80 College Street, Toronto, Ontario, M5G 2E2 Attention: Finance Department Fax: 416-967-2654.

May 2012

Last Name

Last NameFirst Name

Print Form

Reset Form

asdfdsafdsf

awright

Typewritten Text

awright

Typewritten Text

INQUIRY FORM: FEDERATION OF STATE MEDICAL BOARDS ACTION DATA BANK

APPLICANT: Please complete and forward this form directly to the Federation of State Medical Boards at 400 Fuller-Wiser Road, Euless, TX 76039, Fax: (817) 868-4099, E-mail: [email protected].

TO THE FEDERATION OF STATE MEDICAL BOARDS OF THE UNITED STATES: I am applying for a certificate of registration to practise medicine in the province of Ontario, Canada, and before my application can be assessed, information relating to my qualifications and medical practice activities is required. I hereby authorize your releasing to the College of Physicians and Surgeons of Ontario the results of your search for information about me in the Board Action Data Bank. I request a summary report(s) and any appended information to be forwarded directly to:

The College of Physicians and Surgeons of Ontario Applications and Credentials Department 80 College Street Toronto, Ontario

M5G 2E2 My personal details are as follows: Name: Last Name

____________________ ___________________________________________ First Name Middle Name

Date of Birth: ___ _____ ____

Day Month Year _________________________________________________________________________ Medical School: (Include Complete Name and, if applicable, Branch Location) _________ _______________ ___________________________________ Degree Year of Graduation Country of Medical School _________________________ ___ ECFMG Number (for foreign medical graduates) U.S.A. Social Security No. (if applicable) Physician's Signature Date

Updated: September 2012

AFFIX PHOTOGRAPH HERE

Photograph must be full face, of passport size and quality, and taken within the sixty days prior

to submitting the application.

Application for Certificate of Registration Authorizing INDEPENDENT PRACTICE

All questions in this application must be answered in full. Please type or print neatly. Where space provided isinsufficient, attach additional sheets of paper as necessary.

The non-refundable application fee must be submitted with this application.

1. PHOTOGRAPH OF APPLICANT

One black and white or colour photograph must be affixed above. Photograph must be taken full face and be ofpassport photograph size and quality. Photograph must be taken within the sixty days prior to submitting thisapplication. Photographs not meeting these specifications will be returned with this application.

The photograph of me attached hereto was taken on: ______ ______ ______Day Month Year

2. PERSONAL IDENTIFICATION

(a) Full name: _____________________________________________________Last Name

_________________________ _______________________________________________________First Name Middle Names

(b) Have you ever been known by any other names? Yes No

If “Yes,” provide your previous names: _________________________________________Last Name

_________________________ _______________________________________________________First Name Middle Names

(c) Date of birth: ______ ______ ______Day Month Year

CPSO or ADM# _____________________

80 College St., Toronto, Ontario, Canada M5G 2E2(Telephone 1-416-967-2617 or 1-800-268-7096or Fax 1-416-967-2623)

(d) Sex: Male Female

(e) Have you previously applied for or been issued a licence or certificate of registration by the Yes No College of Physicians and Surgeons of Ontario?

If “Yes,” what was your identification number or your licence or certificate number: _______________________________

3. ADDRESS

Both your mailing address and your primary practice address, with corresponding telephone numbers, must be providedbelow. The mailing address you provide will be recorded in the College register and will be used as your official mailingaddress for communications from the College. The primary practice address you provide will also be recorded in theCollege register and will be available to the public on request. Your mailing address will not be publicly available, unlessit is the same as your primary practice address.

If you provide a future mailing or primary practice address, it will replace your present mailing or primary practice address in the College register at the appropriate time.

(a) Present mailing address (include postal code):

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Telephone number: (_________) ____________________ Alternate telephone number: (_________) ___________________Area Code Number Area Code Number

E-mail address (if available): ______________________________________________________________________________

(b) Is your present primary practice address the same as your present mailing address? Yes No

If “No,” provide your present primary practice address (include postal code) and your telephone number:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Telephone number: (_________) ____________________ Alternate telephone number: (_________) ___________________Area Code Number Area Code Number

E-mail address (if available and if different from above): ______________________________________________________

(c) Future mailing address (if known and if different from your present mailing address):

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Future telephone number (if known and if different from above): (_________) ____________________Area Code Number

Effective date of future mailing address: ______ ______ ______Day Month Year

– 2 –

– 4 –

(g) Name of University or Location Dates Language ofSchool of Medicine (From/To) Instruction

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

6. POSTGRADUATE MEDICAL QUALIFICATIONS

(a) Have you passed, before December 31, 1991, Yes No the Medical Council of Canada Qualifying Examination?

Examination date: _______ _______Month Year

(b) Have you passed, after December 31, 1991, Yes No Part 1 of the Medical Council of Canada Qualifying Examination?


(c) Have you passed, after December 31, 1991, Yes No Part 2 of the Medical Council of Canada Qualifying Examination?


(d) Do you hold the Licentiate Certificate of the Medical Council Yes No of Canada (LMCC)?

Date of certificate: _______ _______Month Year

(e) Do you hold certification by examination by the Yes No Royal College of Physicians and Surgeons of Canada?

Specialty:

________________________________________ Certification dates: _____ _______ _______Day Month Year

________________________________________ _____ _______ _______Day Month Year

If “No,” have you passed the written and oral examinations and are now Yes No awaiting certification by the Royal College of Physicians and Surgeons of Canada?

– 5 –

If “No,” have you received an official assessment that you are now eligible to take,

(i) the written examination of the Royal College of Physicians Yes No and Surgeons of Canada?

Expected Examination Date: _______ _______Month Year

(ii) the oral examination of the Royal College of Physicians Yes No and Surgeons of Canada?


(f) Do you hold permanent certification, without examination Yes No by the Royal College of Physicians and Surgeons of Canada?

Specialty:

________________________________________ Certification date: _____ _______ _______Day Month Year

(g) Do you hold certification, by examination Yes No by the College of Family Physicians of Canada?

Certification date: _____ _______ _______Day Month Year

If “No,” have you passed the examination and are now Yes No awaiting certification by the College of Family Physicians of Canada?

If “No,” have you received an official assessment that you are now Yes No eligible to take the examination of the College of Family Physicians of Canada?


(h) Have you passed, before December 31, 1991, the Yes No examinations for the diploma of the NationalBoard of Medical Examiners of the United States of America?

(i) Have you obtained, before December 31, 1991, a score of Yes No seventy-five or better on each of Component 1 and 2 of FLEX(the Licensing Examination of the Federation of State MedicalBoards of the United States of America)?

– 6 –

7. POSTGRADUATE MEDICAL TRAINING COMPLETED IN CANADA OR THE UNITED STATES OF AMERICA

(a) Internship (PGY 1)

DateType/Discipline Medical School/Base Hospital (From/To)

______________________________ ______________________________ ______________________________

______________________________ ______________________________ ______________________________

Was your training performance in all internship rotations and electives rated Yes No as satisfactory by your Program Director?

If “No,” please attach a comprehensive explanation and identify the Program Director involved.

(b) Residencies (PGY 2-7)

DatesDiscipline Medical School Base Hospital (From/To)

PGY 2______________________ ______________________ ______________________ ______________________

PGY 3______________________ ______________________ ______________________ ______________________

PGY 4______________________ ______________________ ______________________ ______________________

PGY 5______________________ ______________________ ______________________ ______________________

PGY 6______________________ ______________________ ______________________ ______________________

PGY 7______________________ ______________________ ______________________ ______________________

Was your training performance in all residencies rated as satisfactory Yes No by your Program Director?


(c) Clinical or Research Fellowships

DatesDiscipline Medical School Base Hospital (From/To)

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

Was your training performance in all clinical or research fellowships rated Yes No as satisfactory by your Program Director?


– 7 –

8. PRACTICE HISTORY

In chronological order, list the names of every jurisdiction where you have practised medicine, including all trainingappointments, since your graduation from medical school. For each period of practice, please provide the correspondinglicence or registration number.

Jurisdiction Nature of Practice Dates Licence or Registration(From/To) Number

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

- 8a -

9. ATTENTION: The following questions relate to professionalism, conduct, character and suitability to practise medicine. Each question must be answered carefully and honestly. Clarify any uncertainties with the College before you answer the questions. If you do not fully understand what a question means or how it should be answered, contact the College for assistance. Any errors, discrepancies or omissions in your answers, no matter how minor, will delay your application and may require review by the College’s Registration Committee. Ensure that you consider any past practice in Ontario when answering the questions and that your answers are consistent with those in any previous application you have made to the College. For every “yes” answer, you must provide sufficient explanation and documentation. Without this, the College cannot proceed with your application. Later in the process, the College may ask you for further explanation or documentation. If the events or circumstances behind any “yes” answer raise reasonable doubts about whether you fulfill the registration requirements, your application must be referred to the Registration Committee for review. Be assured, however, that not every “yes” answer requires Registration Committee review, and that in either case, your honest and frank disclosure will be noted by the College. The College has a non-exemptible requirement for registration that the conduct of the applicant, including the applicant's past conduct, affords reasonable grounds for belief that the applicant:

(i) is mentally competent to practise medicine, (ii) will practise medicine with decency, integrity and honesty and in accordance with the law, (iii) has sufficient knowledge, skill and judgment to engage in the medical practice authorized

by the certificate, and (iv) can communicate effectively and will display an appropriately professional attitude.

Knowingly giving a false answer to any question is grounds for refusal of the application by the Registration Committee and is an offence under s. 92 of the Ontario Health Professions Procedural Code. (a) APPLICATIONS TO MEDICAL LICENSING AUTHORITIES In the following questions, “medical licence” includes any certificate of registration or permit to practise medicine of any type -- full, limited, temporary, provisional, training, etc.

(i) Have you ever applied anywhere for a medical licence and been refused? Yes □ No □

(ii) Have you ever been refused renewal of your medical licence? Yes □ No □

(iii) Are you now applying for a medical licence in any jurisdiction other than Ontario? Yes □ No □

For every “yes” answer, provide a detailed explanation including all relevant names and dates.

- 8b -

(b) ACTIONS BY MEDICAL LICENSING AUTHORITIES In the following questions, “medical licensing authority” includes the College of Physicians and Surgeons of Ontario and any other licensing or regulatory authority that has had jurisdiction over your medical practice.

(i) Regardless of the outcome, have you ever been the subject of any complaint made to

a medical licensing authority? (Note: Be sure to disclose all complaints. Complaints that were dismissed, or closed with no further action, or otherwise resolved in any manner, must still be disclosed.)

Yes □ No □

(ii) Are you now the subject of any complaint made to a medical licensing authority? Yes □ No □

(iii) Have you ever been the subject of any type of investigation, inquiry or proceeding by a

medical licensing authority relating to your professional conduct, competence, capacity, or any other aspect of your medical practice? (Note: Be sure to disclose all medical licensing authority investigations, inquiries or proceedings, including any audits or assessments of your practice.)

Yes □ No □

(iv) Are you now the subject of any type of investigation, inquiry or proceeding by a medical

licensing authority relating to your professional conduct, competence, capacity, or any other aspect of your medical practice?

Yes □ No □

(v) Have you ever had a medical licence revoked, suspended, restricted, limited, or subjected

to any other adverse action? Yes □ No □

(vi) Have you ever voluntarily entered into an undertaking or agreement, or voluntarily

restricted, resigned or surrendered your medical licence, either during or subsequent to an inquiry, investigation or proceeding relating to your professional conduct, competence, capacity, or to any other aspect of your medical practice?

Yes □ No □

(vii) Have you ever been required to enter into an undertaking or agreement, or been required

to restrict, resign or surrender your medical licence, either during or subsequent to an inquiry, investigation or proceeding relating to your professional conduct, competence, capacity, or to any other aspect of your medical practice?

Yes □ No □

For every “yes” answer, provide a detailed explanation and include copies of all relevant documents in your possession.

Later, the College may require you to arrange for the medical licensing authority or other organization involved to forward further information directly to the College.

For each complaint investigation, provide copies of the complaint, your formal response to the complaint, and the decision and reasons. (For complaints in Ontario, you may omit this step.)

(c) LEGAL ACTIONS, SETTLEMENTS AND COURT FINDINGS

(i) Has there ever been any civil proceeding, legal action, insurance or other claim that was in any way related to your practice of medicine or your professional activities?

Yes □ No □

(ii) Is there now any civil proceeding, legal action, insurance or other claim that is in any way

related to your practice of medicine or your professional activities? Yes □ No □

(iii) Have you ever agreed to a settlement or other resolution to avoid or resolve any civil

proceeding, legal action or claim that was in any way related to your practice of medicine or your professional activities?

Yes □ No □

- 8c -

(iv) Has a court ever made a finding against you in respect of a civil proceeding, legal action or

claim that was in any related to your practice of medicine or your professional activities? Yes □ No □

(v) Have you ever been denied professional liability protection or insurance? Yes □ No □

For each action or claim, provide an explanation of the events that led to the action, the patient’s condition at the point

of your involvement, the nature and extent of your involvement, and the degree of your responsibility for the patent’s care. Also, provide copies of the statement of claim or complaint, statement of defence or response, court judgment or court order, and settlement agreement.

For past actions in Canada, contact a Medical Officer at the Canadian Medical Protective Association (CMPA) and authorize a report to be sent to the College that describes the action, your role in the events, and the outcome of the action.

For current actions in Canada, contact the CMPA or your legal counsel and request a report to be sent to the College

that describes the action, your role in the events, and the present status of the action.

For actions outside Canada, contact your legal counsel or insurance carrier and request a report to be sent to the College that describes the action, your role in the events and the outcome or present status of the action.

(d) CHARGES AND CONVICTIONS In the following questions, “ offence” includes driving offences such as impaired driving, dangerous driving, driving while suspended, refusing to give a breath or blood sample, or failing to stop at the scene of an accident – these are all major offences which must be disclosed. You need not disclose minor traffic offences, such as parking violations.

(i) Have you ever pleaded guilty to, or been found guilty of, any offence? Yes □ No □

(ii) Have you ever pleaded no contest or made any similar plea to any charge? Yes □ No □

(iii) Are there any charges now pending against you for any offence? Yes □ No □

(iv) Have you ever been charged or arrested for any offence? Yes □ No □

(v) Have you ever entered a diversion program or other resolution process as an alternative to

conviction or prosecution for an offence? Yes □ No □

For every “yes” answer, provide a detailed explanation and include copies of relevant documents, e.g. conviction,

indictment or summons forms; conditional or absolute discharge orders; other court orders and records.

If you have been granted a pardon for a past conviction, enclose a copy of the pardon document. (e) PRIVILEGES AND PROFESSIONAL EMPLOYMENT

(i) Have you ever been denied privileges or been denied appointment or reappointment to the

medical staff of a hospital or other health facility? Yes □ No □

(ii) Have you ever withdrawn an application for privileges at a hospital or other health facility? Yes □ No □

(iii) Have you ever voluntarily relinquished or changed your privileges or resigned from a

hospital, health facility, or any other place of employment either during, subsequent to or in expectation of, an inquiry, investigation or review that was in any way related to your professional conduct, competence, capacity, or any other aspect of your medical practice?

Yes □ No □

- 8d -

(iv) Have your privileges ever been revoked, suspended, cancelled, reduced or otherwise changed by a hospital or other health facility? Yes □ No □

(v) Have your privileges or legal authority to purchase, prescribe, possess or dispense narcotic,

controlled or designated drugs ever been restricted, reduced, withdrawn or surrendered? (vi) Are you now or have you ever been the subject of any type of investigation, inquiry, review

or action by a hospital, health facility, or any other place of employment relating to your professional conduct, competence, capacity, or any aspect of your medical practice?

(Note: Be sure to disclose all such matters, regardless of outcome.)

Yes □ No □ Yes □ No □

For every “yes” answer, provide a detailed explanation including all relevant names and dates. Arrange for the chief of staff, department head, executive officer, or employer to send directly to the College a report

setting out the circumstances and reasons behind the action.

(f) MEDICAL EDUCATION AND ACADEMIC CONDUCT Undergraduate Medical Education

(i) Have you ever withdrawn from, or been expelled or suspended by a medical school?

(ii) Have you ever been put on probation or remediation by a medical school?

Yes □ No □Yes □ No □

(iii) Have you ever taken a leave of absence of six months or longer from a medical school or

otherwise interrupted your undergraduate medical education for six months or longer? Yes □ No □

(iv) Have you ever transferred from one undergraduate medical education program to another? Yes □ No □

(v) Have you ever been the subject of any type of investigation, inquiry or proceeding relating to

misconduct of any type during your undergraduate medical education? Yes □ No □

Postgraduate Medical Education

(vi) Have you ever been dismissed, suspended or removed from a postgraduate medical training program?

(vii) Have you ever been put on probation or remediation during a postgraduate medical training

program?

Yes □ No □

Yes □ No □

(viii) Have you ever taken a leave of absence of six months or longer from or otherwise

interrupted a postgraduate medical training program for six months or longer? Yes □ No □

(ix) Have you ever transferred from one postgraduate training program to another without having

fully completed the first program? Yes □ No □

(x) Have you ever withdrawn or resigned from a postgraduate medical training program?

(xi) Have you ever been the subject of any type of investigation, inquiry or proceeding relating to

misconduct of any type during your postgraduate medical education?

Yes □ No □Yes □ No □

General

(xii) Have you ever been investigated or sanctioned by any academic, research or medical educational body of any type for any violation of academic policy?

Yes □ No □

- 8e -

For every “yes” answer, provide a detailed explanation including all relevant names and dates.

For “yes” answers relating to training, arrange for the undergraduate dean or the postgraduate dean or program director to send directly to the College a letter setting out the circumstances and reasons behind the matter. Note to Ontario postgraduate trainees: In most cases, a letter from the Dean regarding your leave of absence or any other change in your postgraduate training status will already be on file with the College, so you should omit this step pending further instructions from the College.

(g) MEDICAL CONDITIONS In the following questions, “medical condition” includes any mental disorder or illness.

(i) Do you now have any medical condition that affects or could affect your ability to practise

medicine? Yes □ No □

(ii) Have you ever had any medical condition that has affected or could affect your ability to

practise medicine? Yes □ No □

(iii) Have you ever taken a medical leave of absence, of any duration, from a medical school, a

postgraduate medical training program or any professional position or employment? Yes □ No □

(iv) Do you now have a communicable disease or are you a carrier, whether asymptomatic or

otherwise, of an infectious agent of a communicable disease? Yes □ No □

(v) Are you now abusing, dependent on, or addicted to alcohol or a drug? Yes □ No □

(vi) Are you being treated for abuse of, dependence on, or addiction to alcohol or a drug? Yes □ No □

(vii) Have you ever abused, been dependent on, or addicted to alcohol or a drug? Yes □ No □

(viii) Have you ever been treated for abuse of, dependence on, or addiction to alcohol or a drug? Yes □ No □ For every “yes” answer, provide a detailed explanation.

Arrange for your treating physician(s) to send directly to the College a report on your medical condition setting out

your diagnosis, course of treatment, current health and prognosis. (h) GENERAL

(i) Have you ever ceased or interrupted your medical practice for any reason for six months or

longer? Yes □ No □

(ii) Are you now subject to any contract, agreement, undertaking or obligation with any medical

licensing authority, health facility or other regulatory or governmental body that might be an impediment to your application for a certificate of registration to practise medicine in the province of Ontario?

Yes □ No □

(iii) Is there any event, circumstance, condition or matter not disclosed in your answers to the

preceding questions in respect of your character, conduct, competence or capacity that might be relevant to your application for a certificate of registration to practise medicine in the province of Ontario?

Yes □ No □

For every “yes” answer, provide a detailed explanation.

8f -

(i) UNDERSTANDING, AGREEMENT and THIRD-PARTY AUTHORIZATION

1. I understand that I will be deemed by the College of Physicians and Surgeons of Ontario (the “College”) not to have satisfied the requirements and qualifications for a certificate of registration if, in connection with this application or any past application, I have made a false or misleading representation, either because of what was stated or left unstated.

2. I understand that any certificate of registration that results from this application is void and is deemed to have

always been void if I have made any false or misleading representation or declaration on or in connection with this application, whether by commission or omission.

3. I agree that during the course of this application I will immediately notify the College in writing of anything that

renders any response to the questions in this application, although true and complete when made, no longer true and complete. I understand that failure to notify the College of any such thing may void any certificate of registration that results from this application.

4. I understand that the submission of this application for registration to the College and any registration with the

College that may result, shall constitute and operate as authorization by me for the College to make such inquiries about me of any kind that it considers appropriate in connection with this application and to disclose information about me to other medical licensing authorities, federations of licensing authorities, hospitals and other institutions to which I apply for appointment.

5. I understand that this Understanding, Agreement and Third-party Authorization is valid commencing on the date

subscribed below and that this Understanding, Agreement and Third-party Authorization will remain in force and effect during the course of this application and until I no longer hold a certificate of registration issued by the College.

Dated: ______ ______ ______ ___________________________________________________________

Day Month Year Applicant’s Full Name (Print) __________________________________________________________ Signature of Applicant IMPORTANT: Ensure that you complete the declaration on the following page. Your declaration must be made before a Commissioner for Oaths, Lawyer or Notary Public. Rev. 8/2005 – Part (i) Rev. 2/2011 - Parts (a) to (h)

– 9 –

CPSO 12/09

WARNING

Subsections 92 (1) and (2) of the Health Professions Procedural Code provide: (1) Every person who makes a representation,knowing it to be false, for the purpose of having a certificate of registration issued is guilty of an offence and on conviction isliable to a fine of not more than $25,000; (2) Every person who knowingly assists a person in committing an offence undersubsection (1) is guilty of an offence and on conviction is liable to a fine of not more than $25,000.

DECLARATION

I,Full Name

of the ofType of Municipality Name of Municipality

in the ofProvince or State Name of Province or State

hereby declare the following:

1. I am the person making application for a certificate of registration to practise medicine in the Province of Ontario.

2. The photograph attached to the first page of the application is an unaltered photograph of me taken within the sixty days before the application is made.

3. I have read, understood and signed the application to which this declaration is attached.

4. The answers I have given to the questions in the application to which this declaration is attached are true, complete and without intent to mislead.

5. I understand that I am not permitted to engage in any kind of medical practice in Ontario until I have actually been issued a certificate of registration.

6. If the College of Physicians and Surgeons of Ontario issues a certificate of registration to me, I promise to comply with the regulations and by-laws of the College.

7. I make this declaration conscientiously believing it to be true, and knowing that it is ofthe same force and effect as if made under oath and by virtue of the Canada Evidence Act.

Declared before me in the ofCity, Town, County

in the ofProvince or State

this day of 200 .

Signature of Applicant

Signature of a Commissioner for Oaths, Lawyer or Notary Public

Print Name and Address of Commissioner, Lawyer or Notary Public: Seal, stamp or card ofCommissioner, Lawyer or

Notary Public must be affixed here.