ROMP :: Coordinator Dashboard

Please indicate the focus of your practice:

Other

Hospital Privileges

Primary privileges

Secondary Privileges

Other Privileges

How many exam rooms do you have available?

Average number of Patients seen per day by

Yourself

Resident Trainee

Clerk Trainee

Pre-Clerk Trainee

Distance between your office and the hospital

Is your office/clinic

Wheelchair Accessible

Easily Accessed by Public Transit

Wheelchair Accessible

Do you use Electronic Medical Records?

Yes

No

Is an EMR Orientation provided to learners?

Yes

No

If you use EMR, which product do you use?

Other

Patient Profile

Weekly percentage of time spent

Hospital

Office

Community

Other

Please indicate the average number of half days spent in the office per week

My hospital work is divided between

In-patient Care

ER Shifts

Elective Surgery

Do you perform any of the following procedures in your office?

Other

How do you provide non-obstetrical care to your patients after regular office hours?

Other

Equipment available in your office includes

Other

Average number of Obstetrical Deliveries per month.

Are you part of a

Other

If you belong to a FHT, please identify which one

Do you share an office?

Yes

No

Teaching Information

Will you share teaching?

Yes

No

If Yes, please list other physicians, with whom teaching responsibilities are shared Please specify first and last name only, e.g. "John Smith", "Jennifer Young"

Dr.

Other

Have you participated in teaching before?

Yes

No

Are you comfortable teaching in French?

Yes

No

Are you willing to participate in vertical learning?

Yes

No

Unsure

Please identify if you are part of the following teaching programs

Other

What non-physician staff do you work with? Please also indicate if they participate in teaching.

Staff

Other Staff

Teaching

Other teaching

What are the best months for you to teach?

What horizontal learning in other disciplines exists within your community?

Please indicate your preferred learner

Does your practice have a dress code?

Other

Do trainees require a pager?

Yes

No

Resources available to learners in your office include

Other

Is an Orientation Provided to Learners?

Yes

No

Unsure

If YES, by whom

Other

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
AM
PM
Evening

During a 1 month rotation, please indicate to what a learner could expect to be exposed at your practice

Other

Feedback and Supervision

Describe your usual practice of providing feedback to Medical Students and Clerks for the following:

When is the Student-Patient encounter reviewed?

When are the student's chart entries reviewed?

When is feedback provided to the student

How often do you review the log card with the student?

Describe your usual practice of providing feedback to Physician Assistants and other healthcare trainees for the following:

When is the Student-Patient encounter reviewed?

When are the student's chart entries reviewed?

When is feedback provided to the student

How often do you review the log card with the student?

Describe your usual practice of providing feedback to Residents for the following

When is the Student-Patient encounter reviewed?

When are the student's chart entries reviewed?

When is feedback provided to the student

Please comment on your clinical supervision of Medical Students and Clerks:

Other

Please comment on your clinical supervision of Physician Assistants and other healthcare trainees:

Other

Please comment on your clinical supervision of Residents:

Other

General Questions

How can ROMP enhance your experience as a preceptor?

Are there any obstacles that you have encountered as a Preceptor?

Do you feel that your teaching is

Why have you chosen to teach?

Other

How important is promotion and an academic career to you?

Are you interested in pursuing any of the following?

Video Conferencing(check all that apply)

Don't use video

If you use video, please answer following questions:

Do you use video conferencing at:

Do you use video conferencing for:

Faculty Appointment

If you have a Faculty Appointment, please indicate at which University

Department

Appointment Start Date

Date of Renewal

Department

Appointment Start Date

Date of Renewal

Department

Appointment Start Date

Date of Renewal

If you would like a Faculty Appointment, please indicate at which University

Other

In the last 12 months, have you attended Faculty Development programs through any of the following organizations:

Other

How often do you attend CME events throughout the year?

ROMP Preceptor Application

Contact Information

Medical Information

Practice Information

Teaching Information

Feedback and Supervision

General Questions

Faculty Appointment

ROMP Preceptor Application

Contact Information

Medical Information

Practice Information

Teaching Information

Feedback and Supervision

General Questions

Faculty Appointment

Success!