Assessment Form for Overseas Doctors

* Fields are mandatory
 

Personal Information

Name in full*

Last Name

First Name

Middle Name

Former Name

(Maiden/Former Secular Name)

Preferred Name

Present Address

Number

  Street

Town/City

State/Province

Postal Code

Phone No. & Area Code

Date of birth*

Day   Month   Year

Sex*

Male  Female

Marital Status*

Single Married Widow Divorced Other

Number of Children under 22 years of age

Native or first language

Place of Birth

Email*

Have you ever been convicted of a criminal offence or do you have any outstanding charges

Yes  No

 

 

Non Medical Education

Non Medical Education

Language of Instruction

Country

Date of Entry

Completion Date

Certificate

Primary

Secondary
(High School)

 

 

 

 

 

 

Medical Education: Enter actual name of medical school/program

Name & address of each Medical program attended

Language of Instruction

Date Entered Yr/Month

Date Completed Yr/Mo

Received/Will Receive
(Specify i.e. MD/MBBS)

Diploma/Certificate

Degree

Diploma/Certificate

Degree

 

Have you completed your Post Graduate Training? Yes  No

If yes ,give us details about your training (period ,Location ,etc)  

How many weeks did you spend in each of the following sections:

Internal Diseases

Surgery

Pediatrics

Ophthalmology

ENT

Laboratory

Obstetrics & Gynecology

Dermal Diseases

Gerontology

 

Areas Included in Medical Education Program  and period spent (in weeks) for each section:

 

Medical

Surgical

Maternity

Children

Psychiatric

Community

Gerontology

Theory/Classroom

Practical/Clinical Experience

 

 

 

 

 

 

 

 

Registration Status and medical Experience
Complete all questions. If not applicable, write N/A.

Where did you first obtain registration?

 

State/Province/Country

  Date

What is your legal title in the province/state/country in which you first obtained registration?

In what other provinces / states / countries have you registered?

Have you ever written the Canadian evaluation or qualifying examinations? If yes, record dates and locations of all previous writings

Yes  No  

Is there any reason that you may not be fit to engage in the practice of Medicine?  If yes, explain why?

Yes  No  

Is your Medical conduct or practice currently under investigation? If yes, explain why?

Yes  No  

Have you ever been denied registration? If yes, explain why?

Yes  No  

Have you been disciplined by a  professional regulatory body? If yes, explain why?

Yes  No  

Has your registration ever been  revoked or suspended or had conditions attached? If yes, explain why?

Yes  No  

 

 

Rate your ability to communicate in each of the following areas

English*

Proficiency

Excellent

Moderate

Basic

None

Speak

Listen

Read

Write

 

 

 

 

 

 


French

Proficiency

Excellent

Moderate

Basic

None

Speak

Listen

Read

Write

 

 

 

 

 

Employment Details (if applicable)

Are you working now as a doctor:*

Yes       No

Total Number of years of experience in this occupation:*

Current working place:

When did you start?

 

 

 

 

 

Fill separately all occupation & positions you have occupied since the completion of your formal education (including your current position):

Job Title

From

To

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Spouse's Details (Please answer the following questions if you are married)

Spouse's Age:

Your Spouse Date of Birth:

 

 

 

 

 

Spouse's Education

Total number of years of full-time education officially completed: *

Number of years of Primary/Elementary School Education:

Number of years of Secondary/High School Education:

Number of years of College Education:

Has your spouse obtained diploma?

Yes  No  

Number of years of University Education:

Has your spouse obtained degree? if Yes name it please:

Yes  No 

Name of the University:

Number of years of formal trade apprenticeship / training

Has your spouse taken any additional training/courses in your professional field?
If yes, please list them here

Yes  No  

Has your spouse completed post-secondary program in Canada of at least two years? If yes, please provide details here

Yes  No  

 

 

 

 

 


English*

Proficiency

Excellent

Moderate

Basic

None

Speak

Listen

Read

Write

 

 

 

 

 

 


French

Proficiency

Excellent

Moderate

Basic

None

Speak

Listen

Read

Write

 

 

 

 

 

 

Your Spouse Current occupation:*

Total Number of years of experience in this occupation:*

Your Spouse Current working place:

When did your spouse start?

 

 

 

 

 

Fill separately all occupations & positions your spouse has occupied since the completion of formal education (including current position):

Job Title

From

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has your spouse worked in Canada in a full-time position for at least one year?

Yes  No

How did you hear about us?

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