ROMP Preceptor Application
Upon Completion of this application, please email an updated copy of your CV to romp@romponline.com
Contact Information
First Name:   Last Name:  
Maiden Name:
Practice Address
Clinic Name:
Street:   Unit #/PO Box:
City:   Postal Code:  
Mailing Address 
Street: Unit #/PO Box:
City: Postal Code:  
Office Phone Number:
Office Fax Number:
Alternate Phone Number:
E-mail Address:
 
Are you a Corporation? Corporation Name:
Medical Information
Medical School: Other:
Residency School: Other:
Secondary Residency School: Other:
Date of MD: CPSO Number:
Certificates:



Other:
Did you complete any ROMP rotation as a medical trainee?
Practice Information
Community: Specialty:
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:
Do you use Electronic Medical Records?
Is an EMR Orientation provided to learners?
If you use EMR, which product do you use?
Other:
Patient Profile:



Weekly percentage of time spent: Hospital: Office: LTC:
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?   
Teaching Information
Will you share teaching?   
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. Dr. Dr.
Dr. Dr. Other:
Have you participated in teaching before?   
Are you comfortable teaching in French?   
Are you willing to participate in vertical learning?
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?
Resources available to learners in your office include:
Other:
Is an Orientation Provided to Learners?
If YES, by whom: Other:
Please identify the typical office hours expected of learners:
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
How often do you review the log card with 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)
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?