Community GPO Education Program Application

8 Week Program

Community need for expertise in cancer care is a requirement of acceptance into this program.

Please ensure you have reviewed the Program mandate on the Network Website.

APPLICANT DETAILS

NAME OF APPLICANT:

First Name, Middle Initial, Last Name

ADDRESS

Street # and name, City, Province, Postal Code

TELEPHONE NUMBERS:

Home:

Office:

Mobile:

EMAIL ADDRESS:

INTRODUCTORY MODULE YOU PLAN TO TAKE:

September 9 – 20, 2019

February 3 – 14, 2020

Following the Introductory Module, 30 days of Clinical Rotation will be arranged at the Cancer Centre(s) where your patients are referred. A letter of completion from that Centre and a post program evaluation are required in order to receive credit.

BRIEFLY STATE YOUR REASONS FOR WANTING TO TAKE THE PROGRAM:

CAREER GOAL

POST GPO EDUCATION PROGRAM CAREER GOAL:

BC/Yukon Community GPO

Other – please specify

COMMUNITY DETAILS AND ONCOLOGY EXPERIENCE

Do you have the support of your local medical community to take this program? Yes No

What commitment do you have to becoming an identified oncology leader/facilitator in your community?

Please provide information on your local medical community, focusing on oncology services and support (examples: Oncologists, GPOs, Internists, Surgeons, Diagnostic Services, Palliative Care):

Is there a chemotherapy clinic operating in your community? Yes No

Describe and explain your experience with cancer patients:

CURRENT PRACTITIONER INFORMATION

MEDICAL SERVICES PLAN (MSP) PRACTITIONER #:
Permanent #

Temporary # – Expiry Date

Other – Explain

COLLEGE OF PHYSICIANS & SURGEONS OF BC LICENSE #:

Permanent #

Temporary – Expiry Date

Other – Explain

Are you a member in good standing?	Yes No

CURRENT CANADIAN MEDICAL PROTECTION ASSOCIATION (OR ALTERNATE) #

DO YOU HAVE HOSPITAL PRIVILEGES? Yes No

If yes, list hospital(s) and associated Health Authority?

REQUIRED ATTACHMENTS AND REFERENCE

PLEASE INCLUDE THE FOLLOWING WITH YOUR APPLICATION:

Letter of reference identifying the need and willingness of your community to utilize your enhanced skills from the Chief of Staff or equivalent;

Professional reference letter

Personal reference letter as to your personal capabilities and qualities

Statement outlining your reasons for pursuing enhanced skills, including identification of specific community need

Current Curriculum Vitae

SUBMIT YOUR APPLICATION BY EMAIL

Ensure all documentation is available prior to submitting your application. Please email your complete application – including all attachments – as one PDF document (with this application form at the front) to:

Jennifer Wolfe, Program Manager

Family Practice Oncology Network

BC Cancer

600 W. 10th Ave.

Vancouver, BC V5Z 4E6

T: 604 219 9579

jennifer.wolfe@bccancer.bc.ca

Kindly submit your application at your earliest convenience. We thank you for your interest and will advise you promptly as to your acceptance into the program.

FUNDING SUPPORT

Only those intending to complete the full 8-week program are eligible.

Applicants from REAP eligible communities should complete a REAP Application and submit to Hillary Kovac at UBC’s Dept. of Family Medicine, T: 604 827 1504. F: 604 822 6950

Applicants from other BC communities should complete an R3 Enhanced Skills Application and submit to Ingrid Ahlsten at UBC Faculty of Medicine’s Enhanced Skills Program, T: 604 822 0869, F: 604 822 6950

Participant can also apply for a scholarship from the Canadian Association of General Practitioners in Oncology.

GPO Education Program Application	3

Application for Family Practice Oncology Preceptor Program

Mahil, Dilraj

2019-05-22

BCCA