REGISTRATION FORM 

The following information is being collected to help us to better represent foreign trained doctors in Ontario.   Individual names and personal information will be kept strictly confidential.

CONTACT INFORMATION

Surname
Given Name
Street Address
Apartment/Unit/Suite Number
City
Province
Postal Code
Email
Home Phone
Work Phone
Fax
 
 
Are you willing to participate in a focus group on issues facing foreign trained doctors?  (Yes   No)
Are you willing to be individually interviewed about your experiences?  (Yes   No)
Do you want to be contacted for general membership meetings of the FTDA?  (Yes   No)
 

PERSONAL INFORMATION

AGE GENDER IMMIGRATION TO CANDA STATUS
<30    Male     Date of Arrival    Landed Immigrant   
30-39 Female Country of Birth Refugee Claimant   
40-49   Nationality          Convention Refugee
50-59     Citizen                   
60-69 LANGUAGE (list in order of fluency)  
70+     



MEDICAL TRAINING AND EXPERIENCE

  1. Please include all post-secondary education (eg. MD, postgraduate training, specialization, etc.)

    Degree/Training
    Years (From/To)
    University/Institute
    Country

  2. In what country(ies) have you practiced as a medical doctor?

  3. How many years have you practiced as a medical doctor?

  4. If you have specialized, what is your area(s) of specialization?

  5. How many years have you practiced as a specialist?

  6. Do you have experience in the Canadian healthcare system?  If yes, please specify. (dates, employer, position)




CANADIAN LICENSING

Exam
Date Written (month/year)
Date Passed (month/year)
Evaluating Exam
Qualifying Exam Part 1
International Medical Graduate (IMG) Exam
Objective Structure Exam (IMG - Oral)
Qualifying Exam Part 2
US Exams
Other (specify)

If you have not written any exams, do you plan to do so in the future?
Yes    No

If yes, for Canada?   the United States?  

EMPLOYMENT OBJECTIVES

  1. Are you currently working in a related medical profession?
    Yes    No
         If yes, please specify

  2. Are you pursuing alternate professions where your skills will be used?
    Yes    No
         If yes, please specify

  3. Are you taking or planning to take training for an unrelated occupation?
    Yes    No
         If yes, please specify