2017 ACFP Shadowing Program U of A - Physician Pre-Shadow Application

The Alberta College of Family Physicians (ACFP) in support from our sponsors the Alberta Medical Association Sections of General Practice and Rural Medicine are happy to welcome you to the 2017 Shadowing Program for Incoming Medical Students! Your responses to this pre-shadow application will assist us in making the best possible match for you with a first year medical student. Thank you for your interest in the 2017 Shadowing Program and for taking the time to complete this short application.

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* 1. Contact Information - please provide the contact information of where the student will be shadowing:

Name (First and Last):

Clinic Address(this address will be provided to the student):

City/Town:

Postal Code:

Clinic telephone number:

Email (please provide an email address that can be shared with the student):

Cell phone: (if communication with student via cell phone is preferred, please provide this number)

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* 2. The following is a list of family physician work settings. Please check the category or categories which best describes your medical setting. This will help us to better match a medical student's interests with your
location.

Private office/clinic (excluding free standing walk-in clinics)

Community clinic/Community health centre

Free-standing walk-in clinic

Community hospital

Emergency department

Long Term Care/Supportive/Assisted Living

Other (please specify)

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* 3. The U of A Medical Student Shadowing Program is scheduled August 14 to 25, 2017. Are there any days between August 14 to 25, 2017 when you would not be available to have a student shadow you, please identify them. Should your schedule change prior to the shadowing program starting, please contact Jody at the ACFP office at jody.tol@acfp.ca to advise her as soon as possible. Your availability dates are used when matching with the availability of the students.

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* 4. Is your clinic open during the following days (please select all that apply):

Monday to Friday Only

Saturday

Sunday

Other (please specify)

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* 5. Is your clinic open during evening hours? If yes, during which times?

Monday to Friday

Saturday

Sunday

Not Open Evening Hours

Other (please specify)

2017 ACFP Shadowing Program U of A - Physician Pre-Shadow Application

Question Title

* 1. Contact Information - please provide the contact information of where the student will be shadowing:

Question Title

* 2. The following is a list of family physician work settings. Please check the category or categories which best describes your medical setting. This will help us to better match a medical student's interests with your
location.

Question Title

Question Title

* 4. Is your clinic open during the following days (please select all that apply):

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* 5. Is your clinic open during evening hours? If yes, during which times?

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* 6. Would a student of a specific demographic receive more benefit from shadowing in your office, due to a second language fluency or similar?

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* 7. Thank you for volunteering for the Shadowing Program. Additional comments/questions?

Question Title

* 1. Contact Information - please provide the contact information of where the student will be shadowing:

Question Title

* 2. The following is a list of family physician work settings. Please check the category or categories which best describes your medical setting. This will help us to better match a medical student's interests with yourlocation.

Question Title

Question Title

* 4. Is your clinic open during the following days (please select all that apply):

Question Title

* 5. Is your clinic open during evening hours? If yes, during which times?

Question Title

* 6. Would a student of a specific demographic receive more benefit from shadowing in your office, due to a second language fluency or similar?

Question Title

* 7. Thank you for volunteering for the Shadowing Program. Additional comments/questions?

* 2. The following is a list of family physician work settings. Please check the category or categories which best describes your medical setting. This will help us to better match a medical student's interests with your
location.