PPR-NL Pre-screening Questionnaire

Full Name(Required)

Full Name

Date of Birth(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone(Required)

Fax

Email(Required)

University of Medical Degree(Required)

Year Internship/Residency Completed(Required)

Type of Training(Required)

Please describe your practice(Required)

Is your practice:(Required)

Office Based

Hospital Based

How many years have you been in your current practice?(Required)

Are you currently on medical/maternity leave?(Required)

Yes

If yes, expected date of return:

Do you plan to retire within the next twelve months?(Required)

Yes

If yes, expected date of retirement:

Have you been assessed during the last five years for licensure, certification, or other reasons (i.e., full medical license in Canada, certification by the Royal College of Physicians and Surgeons of Canada or College of Family Physicians of Canada), or in the past five years have you been the subject of a College review?(Required)

Yes

If yes, please provide details, including date of assessment/review:

Any additional information you would like to provide may be noted below:

Full Name(Required)

Full Name

Date(Required)

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