Colchester East Hants Health Authority
MEDICAL/DENTAL STAFF APPLICATION FORM
To be completed in its entirety by all new applicants.
Mail to:
Chief of Staff/Medical Director
Colchester Regional Hospital
207 Willow Street
Truro, NS
B2N 5A1
Phone:
902 893-5554 ext 2377
Fax:
902 893-7653
Name of Applicant:
Date:
References: Every new applicant to Colchester East Hants Health Authority must provide two
references in the medical profession with whom the applicant has been closely associated
in training or previous appointments.
This application will not be considered until all references are received, and evidence of current
licensure with the College of Physicians and Surgeons of Nova Scotia/Provincial Dental Board of Nova
Scotia, and appropriate coverage with the Canadian Medical Protective Association/Canadian Dental
Service Plans Inc. is provided.
In making application for appointment to the Medical Staff of Colchester East Hants Health
Authority, I agree to abide by the Bylaws of the Colchester East Hants Health Authority, and
the Rules and Regulations of the Medical Staff, a copy of which I have received and read. I
agree to abide and be governed by the Code of Ethics as adopted by the Canadian Medical
Association and the Royal College of Physicians and Surgeons of Canada. It is also agreed
that the appropriate authorities of Colchester East Hants Health Authority may contact any
person or organization named in the application to verify the accuracy of information provided
and may solicit such further information from these or other sources as may be deemed
necessary in consideration of this application.
MD
Signature of Applicant
All responses will be considered material both as to the initial appointment and reappointment
by the governing authority of the hospital.
APPLICATION FOR APPOINTMENT TO THE MEDICAL/DENTAL STAFF OF
COLCHESTER EAST HANTS HEALTH AUTHORITY
SECTION A
1.
Name in Full:
Date:
Last
2.
First
Office Address:
Office Phone:
3.
Middle
Postal Code
Office Fax:
Residence Address:
Resident Phone:
Email:
4.
Physical or mental disabilities which would impair your ability to perform the duties of the position for
which you have applied:
5.
Date of Birth:
6.
Medical Education:
College/University
Degree
Date of Graduation
Other Degrees
7.
Licensed to Practice: Province
(Please attach copy of current license.)
Year
8.
Member of CMPA/CDSPI or other malpractice and liability insurance in force:
(Please attach copy of membership card to application.)
9.
Have you ever been the subject of disciplinary action by any licensing Authority?
If yes, give date and name and address of Licensing Authority
10.
Have you ever been convicted of a criminal offence under the Criminal Code of Canada or in another
jurisdiction?
If yes, give details:
11.
List malpractice suits against you, either settled or pending:
Page 2
SECTION B
1.
Post Graduate Training including Fellowships:
University
Speciality
Period
2.
Certification Canadian College of Family Physicians
3.
Specialty Standing: Fellow of the Royal College of Physicians & Surgeons of Canada
Specialty
Year
Year
College of Physicians and Surgeons of Nova Scotia/
Provincial Dental Board of Nova Scotia
Year
SECTION C
1.
Teaching Appointments:
Hospital
2.
Date
Membership on other hospital staffs (past and present):
Hospital
Date
Page 3
3.
Have your ever been denied membership on a hospital medical staff or had privileges
altered, revoked or suspended?
 Yes
 No
If yes, give name of Hospital(s), reason, and date:
Hospital
4.
Reason
Date
Membership in Medical and Specialist Societies:
Name
Date
SECTION D
Honorary or other Special Awards:
Award
Date
SECTION E
References:
Name
Address
Please ensure references are attached to this application or forwarded to the Chief of
Staff/Medical Director to complete application.
Page 4
SECTION F
The applicant hereby applies for (circle appropriate category):
Active
Honourary
Associate
Consulting
Itinerant Consultant Locum Tenens
Courtesy
Dental
Residents/Medical Students Consulting
Membership on the Medical Staff of Colchester East Hants Health Authority and for privileges
of practice as indicated herewith:
1.
FAMILY MEDICINE:
2.
SPECIALTY DEPARTMENT:
3.
PROCEDURAL PRIVILEGES: Please complete attached procedure list.
4.
CRITICAL CARE:
Obstetrical privileges requested:  YES
 NO
 YES  NO If yes, please provide supporting documentation.
Requirements for ICU attending staff include:

Minimum two to four months or equivalent adult ICU training;

Evidence of ongoing CME directed specifically toward critical care medicine;

Sufficient recent ICU experience to maintain a critical care knowledge base and skill set.
Examples may include minimum 25% of inpatient care volume dealing with critically ill patients,
and multiple cases per month (one or two cases per month of modest intensity is insufficient);
and

Demonstrated competency with skill sets necessary to act as attending staff: e.g. ventilator care,
hemodynamic monitoring, complex case management, etc.
5.
EMERGENCY DEPARTMENT:
First Call –  YES  NO







ACLS and ATLS;
Pediatric resuscitation certification – PALS OR APLS desirable;
Maintenance of 200 hours/year experience in Level III Emergency Room;
Twenty-five credits/year of Emergency Medicine CME;
Skill in procedures, as may be defined by head of department;
Attendance at 50% or more of departmental meetings; and
Appropriate participation in on-call/callback schedule.
Second Call –  YES

If yes, please provide supporting documentation.
 NO
Appropriate participation in on-call/callback schedule and meetings.
Page 5
SECTION G
1.
Continuing Medical Education: A minimum of thirty (30) hours of documented CME is required
yearly. An average of sixty (60) hours minimum over two years is acceptable if there is a shortfall.
According to the Rules and Regulations of the Medical Staff, continuation of privileges requires
compliance with the above.
There are two categories of CME credits:
1.
2.
Self learning; and
Approved courses.
A maximum of 50% of required hours may be claimed by Category 1. There is no maximum percentage
hours for Category 2.
Category 1: This group includes journal reading tapes, videos, preparation of papers for publication,
and preparation of lectures.
CME
Hours
CME
Hours
TOTAL HOURS FOR CATEGORY 1 =
Category 2: This group includes seminars, lectures, workshops, clinical traineeships, recertification,
and self learning programs approved by colleges. In addition, it includes hospital based
lectures and CME programs. It also includes Quality Improvement Programs and
preparation of papers for presentation and/or publication.
CME
Hours
CME
Hours
TOTAL HOURS FOR CATEGORY 2 =
2.
Date of ACLS Certification or Recertification:
Page 6
Colchester Regional Hospital
PLEASE CIRCLE THE NUMBER OF THE PROCEDURE YOU WISH TO APPLY FOR
Medical Staff Procedure
List
Anesthesia
1.
2.
3.
General Anesthesia
Spinal Anesthesia
Epidural Anesthesia
4.
5.
6.
Regional Anesthesia
IV Regional Anesthesia
Local Infiltration Anesthesia
7.
8.
9.
9.
Diagnostic and Therapeutic Injection
and Drainage of Joints
Diagnostic Lumbar Puncture
Radial or femoral Artery Cannulation
Central Venous Cannulation by
Jugular or Subclavian Femoral
Route
Pericardiocentesis
a) Emergency
b) Elective
Emergency Defibrillation
15.
Transtracheal Needle Aspiration for
C&S
Needle Biopsy of Pleural
Needle Biopsy of Lung Lesion
Small Bowel Biopsy
Needle Biopsy of Liver
Esophageal Dilation
13.
Elective Intubation
Ventilation in ICU
Other -
Medicine
Family Medicine/Emergency
1.
2.
3.
4.
5.
6.
7.
8.
Peripheral Venipuncture
Arterial Puncture
Endotracheal Intubation
Emergency Insertion of Closed
Chest Tube Drainage
Interim ECG interpretation
Interim X-ray interpretation
Interim laboratory interpretation
Diagnostic & Therapeutic
Thoracentesis
10.
11.
12.
13.
14.
16.
17.
18.
19.
20.
Oral or Parenteral Administration of
Chemotherapeutic Drug Treatment of
Neoplastic Disease
Bone Marrow Aspiration or Biopsy
Abdominal Paracentesis
Administration of Total Parenteral
Nutrition with supervision
Inhalation Analgesia in Obstetrics
Other -
Internal Medicine
1.
2.
3.
4.
5.
6.
Interpretation and reporting of
ECG.
Interpretation and reporting of
Pulmonary Function Tests
Swan-Ganz Catheter Insertion
Elective D.C. Cardioversion
Exercise Stress
Electrocardiography
Insertion of temporary
Transvenous Pacemaker
7.
8.
9.
10.
11.
12.
14.
15.
16.
17.
Needle Aspiration or Biopsy of
Thyroid Lesion
Insertion of Catheter for Peritoneal
Dialysis
Needle Aspiration of Lymph Node
Endocrine Stimulation and Inhibition
Testing
Holter Monitoring Interpretation
Surgery
Surgical Procedures - Minor Operations
1.
2.
3.
4.
5.
6.
I & D of
A. Superficial abscesses
B. boils
C. carbuncles
D. furuncles
E. pilonidal abscess
F.perianal abscess
G. felon
H. paronychia
I. hematoma
Removal of superficial foreign
body
Biopsy of skin and subcutaneous
lesions
Removal of sebaceous cyst
Removal of ingrown toenail
Removal of lipoma, neuroma, and
warts
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Removal of skin carcinomas
Removal of skin carcinomas with skin
grafting up to 1 sq. inch
Suture of superficial wounds and
lacerations above the deep fascia
Care of minor burns
Drainage of breast abscess
Excision of the ranula
Treatment of condylomas and local
excision of the vulvovaginal lesions
and biopsies
E.U.A.
Biopsy of cervix
Cauterization of the cervix
I.U.D.
18.
Bartholin's cyst and abscess
Urethral caruncle
Conization of cervix
12.
13.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
Removal of foreign bodies from nose
& ears
Nasal pkg. for epistaxis
Plaster casts
Spicas
Drainage of bursae excluding removal
of bursa
Split thickness skin grafts up to one
sq. inch
Full thickness skin grafts up to one
sq. inch
Urethral dilatation
Circumcision
Vasectomy
Removal of ganglions and xanthomas
Other -
Surgical Procedures - Intermediate Operations
1.
2.
Removal of pilonidal sinus
Removal of skin tumours
excepting malignant melanoma
6.
7.
8.
Manipulation of joints under GA
Repair of traumatic amputations of
the digits
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3.
4.
5.
Breast biopsy
Caut. of leukoplakia
Hysterosalpingogram
9.
10.
11.
Closed reduction of
a) Minor Fractures
b) Dislocations
Insertion of Kirschner wires
Hymenectomy
14.
15.
16.
17.
18.
Minor amputations of toes
D & C with suction
D & C (diag)
Repair of Extensor Tendons
Other -
Skin grafts where flaps are
transferred
All operations on the eye
Open operations on nasal sinuses
Kidney operations
Prostate operations
Bladder operations
Operations on larynx and trachea
13.
14.
Operations on middle or inner ear
Operations on thyroid or salivary
glands
Myringotomy and Tube placement
Tonsillectomy
Adenoidectomy
Gynecologic Laser:
a) cervix/vulva/vagina
b) Intraperitoneal
Surgery
Surgical Procedures - Major Operations
1.
2.
3.
4.
5.
All operations where a body
cavity is opened - abdomen,
pelvis, thorax
All operations on bones or joints
All operations on tendons, nerves,
major blood vessels
Repair of hernias
A & P repairs
6.
7.
8.
9.
10.
11.
12.
15.
16.
17.
18.
Obstetrics/Gynecology
Category I
Normal antepartum and postpartum care. Uncomplicated labour and delivery. Maternal/fetal monitoring. Local and pudendal
anaesthesia. Episiotomy and repair 2nd degree laceration. Amniotomy with fetal head in mid-low pelvis. Oxytocic in 3rd stage
and for augmentation of first stage in otherwise complicated primigravida labour, outlet forceps and low cavity vacuum delivery.
Category II
Category I +
named
procedures:
Low Forceps & Mid Forceps
Vaginal breech delivery
Repair 3rd degree tear
Amniotomy
Manual removal of placenta/
exploration postpartum uterus
Vaginal delivery of twins
Moderate risk antepartum and postpartum care
Category III C-Section. Repair of 3rd/4th degree perineal tear
Category IV Full OB. All C-Sections. All vaginal deliveries. Moderate/high risk pregnancies. Amniocentesis/Obstetric Ultrasound
*NOTES: Criteria for each Category:
I Physician with basic degree training in obstetrics.
II Basic degree training + further training/experience. For new physicians coming on staff, documentation of expanded experience/training.
III Surgical Fellowship.
IV Completed residency OB/GYN. OB/GYN fellowship. Documented training/experience for expanded privileges
Laboratory Medicine
1.
2.
3.
4.
Autopsy including medicolegal
autopsies
Surgical pathology, examination
of gross specimens
Surgical pathology, microscopic
examination and diagnosis
Surgical pathology, microscopic
examination and diagnosis with
supervision
5.
6.
7.
8.
Surgical pathology, frozen section
Diagnosis
Chemistry laboratory supervision
Cytology - Fine Needle Aspiration
Hematology laboratory supervision
and bone marrow interpretation
9.
10.
11.
12.
Microbiology and infection control
supervision
Blood band & immunology
supervision
Consultations (OR & clinical)
Other -
Diagnostic Imaging
1.
Diagnostic Medical Imaging
2.
Interventional Radiology
3.
Other -
1.
2.
Proctoscopy
Sigmoidoscopy
a) Rigid
b) Flexible
Colonoscopy
4.
5.
6.
7.
8.
Gastroscopy
Cystoscopy
Colposcopy
Bronchoscopy
Hysteroscopy
a) Diagnostic
b) Therapeutic
9.
Laparoscopy
( ) • Diagnostic
( ) •Cholecystectomy
( ) •Appendix
( ) •Tubal Ligation
( ) •Operative Laparoscopy
Arthroscopy
Endoscopy Procedures
3.
10.
Psychiatry
1.
ECT
2.
Sodium Aytol Interview
3.
Hypnosis
Page 8
Colchester East Hants Health Authority
PHYSICIAN PAYROLL INFORMATION SHEET
Employee No. _____________________
Department ______________________
Will be completed by payroll
LAST NAME
FIRST NAME AND INITIAL
ADDRESS
ADDRESS
POSTAL CODE
SIN
DATE OF BIRTH DAY/MONTH/YEAR
TELEPHONE NUMBER
EMAIL
NAME TO PRINT ON T4 (Inc ?)
Please provide the necessary banking information and authorization in order to facilitate direct
deposit of your earnings. Please provide a VOID cheque or a copy of the front page of you
pass book if it is a savings account.
BANK
BRANCH ADDRESS
BANK NUMBER
TRANSIT NUMBER
ACCOUNT NUMBER
I authorize the District Health Authority to credit payment due to my account with the
bank/financial institution designated above. I will advise the Board of any change in my bank
account as soon as it is necessary.
__________________________________________
Signature
Date
Please mail form to: Payroll Office
Colchester Regional Hospital
207 Willow Street
Truro, NS
B2N 5A1
If you have any questions, please call the Payroll Office at 893-5554 (2379)
C:\Conversions\CREDENTI\PHYSICIAN PAYROLL INFORMATION SHEET.doc
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