Pediatric Postgraduate Education Program

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Pediatric Critical Care Subspecialty Training Program
McMaster University
Research/Scholarly Activity Learning Contract
RESIDENT NAME: ____________________________________________
Year of Training:
 1st
 2nd
 3rd
Activity Type and Period:
 Horizontal (dedicated one day/week); Start Date: _ _/_ _ _/_ _ _ _ End Date: _ _/_ _ _/_ _ _ _
 Block (3 months in 2nd year of training); Start Date: _ _/_ _ _/_ _ _ _ End Date: _ _/_ _ _/_ _ _ _
 __ month(s) Elective Block request; Start Date: _ _/_ _ _/_ _ _ _
End Date: _ _/_ _ _/_ _ _ _
Learning objectives and evaluation of outcomes must be discussed with, and agreed upon by
research/scholarly activity supervisor.
Project Title:________________________________________________________________
Learning Objective
Tasks & Strategies (how I’m going
to achieve these objectives)
Medical Expert
Communicator
Collaborator
Manager
Draft Version 3 July 2014
Outcome (what I will
achieve at the end of this
activity period)
Health Advocate
Scholar
Health
Professional
 I have reviewed this submission by Dr. ______________________. We have agreed upon
the learning objectives and outcomes outlined above
 Periodic face-face evaluations will be conducted every __________________
The final written evaluation will be submitted at the end of this Activity period
Supervisor: Name_________________________
Signature______________________
Date: _____________
For “Block” activity, please attach Abstract/Proposal and letter of Support from
research supervisor
 Attached
DATE submitted: _ _/_ _ _/_ _ _ _
Date APPROVED: _ _/_ _ _/_ _ _ _
___________________________________
Program Director’s Signature
Please return completed form to Kay Johnson, HSC 3Y
Draft Version 3 July 2014
___________________
Date
Draft Version 3 July 2014
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