Resident Rotation Evaluation v2

1. Rotation Information

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1. Please fill out the following information: (Required.)

Name:

Preceptor(s) (list all):

Core or Elective Rotation:

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2. In which community you did your rotation? (Required.)

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3. In which clinic/hospital you did your rotation? (Required.)

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4. Rotation Dates: (Required.)

Start Date:

Date

Finish Date:

Date

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5. University: (Required.)

McMaster University

University of Western Ontario

University of Toronto

Queen's University

University of Ottawa

Northern Ontario School of Medicine University

Toronto Metropolitan University

Other (please specify):

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6. Which rotation/s you had done during your rotation dates? (Required.)

Addiction Medicine

Allergist

Anesthesia

Cardiology

Critical Care Medicine (ICU)

Dermatology

Emergency Medicine

Endocrinology

Family Medicine

Gastroenterology

General Surgery

Geriatrics / Gerontology

Hematology

Hospitalist

Infectous Disease

Internal Medicine

Nephrology

Neurology

Neurosurgery

Obstetrcis/Gyn.

Oncology

Opthalmogloy

Ortho Surgery

Otolaryngologist

Palliative Medicine

Paediatric Neurology

Paediatrics

Pathology

Physical Medicine, Rehab

Plastic Surgery

Psychiatry

Public Health and Preventive Medicine

Radiology

Respirartory Medicine

Rheumatology

Sports Medicine

Surgery

Thoracic Surgery

Urology

Vascular Surgery

Other (please specify)

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7. Year in Program (Required.)

PGY1

PGY2

PGY3

PGY4

PGY5

PGY6

Other (please specify)

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8. Which community choice did you receive? (Required.)

First Choice

Second Choice

Third Choice

Other (please specify)

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9. Please identify your main reason(s) for participating in a ROMP-facilitated rotation: (Required.)

Mandatory Rural Rotation

Community-Specific (wanted experience in a specific community, close to home, etc.)

Preceptor-Specific (wanted to work with a specific physician)

Recommended by peers/others

Received Information from Info Session/Website

Other (please specify):

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* 1. Please fill out the following information: (Required.)

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* 2. In which community you did your rotation? (Required.)

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* 3. In which clinic/hospital you did your rotation? (Required.)

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* 4. Rotation Dates: (Required.)

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* 5. University: (Required.)

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* 6. Which rotation/s you had done during your rotation dates? (Required.)

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* 7. Year in Program (Required.)

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* 8. Which community choice did you receive? (Required.)

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* 9. Please identify your main reason(s) for participating in a ROMP-facilitated rotation: (Required.)

1. Please fill out the following information: (Required.)

2. In which community you did your rotation? (Required.)

3. In which clinic/hospital you did your rotation? (Required.)

4. Rotation Dates: (Required.)

5. University: (Required.)

6. Which rotation/s you had done during your rotation dates? (Required.)

7. Year in Program (Required.)

8. Which community choice did you receive? (Required.)

9. Please identify your main reason(s) for participating in a ROMP-facilitated rotation: (Required.)