ROMP :: Coordinator Dashboard

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Position Type

Residency Program

Stream

Program

Personal Information

First Name

Last Name

Gender

Male

Female

N/A

Use of Car

Home Town

Phone Number

Street

Postal Code

City

Email

School Information

Current University

Out of Province University

Date of MD

Other University

Student Number

CPSO Number

Year Of School

Please specify

Clerk

CMPA Number

Medical University

Out of Province Medical University

Year of Residency Completion

Rotation Information

From Date

To Date

Number of Weeks

Rotation Type

Preceptor, if known

Rotation Discipline

I Give Permission to select another community location if my choices are unavailable.

Expectations of Learning Experience

Please clearly indicate any educational expectations (clinic, hospital or other) to ensure that you are matched with a preceptor who meets your learning objectives. Please also note any additional details regarding community placement, or accommodation requests in the notes section below.

Program Coordinator Notes

Please add your program coordinator information and pertinent contact details.

Name of Program Director

By submitting this application, I agree to abide by all of the policies (available at http://romponline.com/wp-content/uploads/2014/09/ROMP-PreceptorLearnerPolicyManual2011.pdf) and confirm that I have not applied to any other rural placement programs. I understand that once the ROMP coordinator has contacted me with the name of a preceptor, it is unprofessional for me to cancel the rotation. I acknowledge that ROMP will notify my school of any unprofessional behaviour.

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Funded

Split Rotation

Preceptor Amount

Preceptor Cheq. Ref.

Learner Travel Amount

Learner Cheq. Ref.

Learner Accom Amount

Learner Accom Cheq. Ref.

Invoice Sent

Preceptor Invoice Sent Date

Administration Notes

Accommodation Name :

Accommodation Type :

Payment Amount :

ROMP Pays Directly

Accommodation Booking Notes

Community Notes

Application - Learner

Personal Information

School Information

Rotation Information

Expectations of Learning Experience

Program Coordinator Notes

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