POSTGRADUATE REGISTRATION FORM
2012-2013
Last Name Click here to enter text.
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DOB (dd/mm/yyyy)
First Click here to enter text.
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CPSO Number
Middle Click here to enter text.
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CMPA Number
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U of T Trainee ID
Current Local Address and Postal Code Click here to enter text.
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Email Address 1 (checked most)
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Email Address 2
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Home Phone
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Cell Phone
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University Program Name
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OneMail Address
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text.
Planned Service Rotations and dates at UHN for Registration Period
Training Level: Click here to enter text.
Non UofT Medical School if on Elective: Click here to enter text.
I have been mask fit tested (yes/no): Click here to enter text.
Date mask fit tested: Click here to enter text.
Clinical Fellows: I have read and signed the Income Tax Withholding letter (yes/no): Click here
to enter text.
Surgical Residents: I have been given the ORSOS form (yes/no): Click here to enter text.
Registration Period:
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Start Date: dd/mm/yyyy
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End Date: dd/mm/yyyy
My signature below confirms that:
1) I have registered with the University of Toronto, Faculty of Medicine for the period above.
2) I have read the Guidelines for Ethics and Professionalism In Health Care Professional Clinical Training and Teaching
3) I agree to adhere to all hospital by-laws and policies.
4) The above information is being collected to be used for the purposes of facilitating placement at UHN as well as to meet
Ministry of Health and Long-Term Care (MOHLTC) reporting requirements. Nothing contained in this form will be disclosed
without my consent, except as requested by the MOHLTC. For more information regarding MOHLTC reporting requirements,
please refer to the Medical Education Office for a copy of the MOHLTC Notice on this subject.
Signature:______________________________________Date:________________
PLEASE SEE BACK PAGE FOR CONFIDENTIALITY AGREEMENT
3/16/2016
PGME UHN Registration Form – 2012/13
CONFIDENTIALITY AGREEMENT
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Name:
(Please Print)
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Affiliation with UHN:
(For example: employee, clinician, physician, allied health, volunteer, researcher, student, consultant, vendor,
contractor)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
During my association with University Health Network (UHN), I will have access to information and material relating to patients, medical
staff, employees, other individuals, or UHN, which is of a private and confidential nature.
At all times, I shall respect the privacy and dignity of patients, employees, and all associated individuals.
I shall treat all UHN administrative, financial, patient, employee and other records as confidential information, and I will protect them to
ensure full confidentiality, including, but not limited to, de-identifying the data, whenever possible. I shall not read records or discuss,
divulge, or disclose such information about UHN, unless there is a legitimate purpose related to my association with UHN. This obligation
does not apply to information in the public domain. I shall not remove confidential information from UHN premises except when necessary
for the provision of health care. When in transit, I shall securely store and ensure the confidential information is in my custody and control at
all times. If confidential information must be removed from UHN, I shall ensure it is de-identified, where possible.
I shall ensure that confidential information is not inappropriately accessed, used, or released either directly by me, or by virtue of my
signature or security access to premises or systems.
Violations of this policy include, but are not limited to:

accessing information that I do not require for job purposes;

misusing, disclosing without proper authorization, or altering patient or personnel information,

disclosing to another person your user name and/or password for accessing electronic records.
I shall only access, process, and transmit confidential information using hardware, software, and other authorized equipment, as required
by the duties of my position. I shall store all electronic confidential information on a UHN secure network. Where electronic confidential
information is stored on the local drive, I shall ensure it is de-identified, where possible. I shall report any tools or software requiring hard
drive storage for patient care functions to the UHN Privacy Office.
I shall immediately report all lost or stolen confidential information to my immediate supervisor and to the UHN Privacy
Office.
I understand that UHN will conduct periodic audits to ensure compliance with this agreement and its privacy policy.
I understand and agree to abide by the conditions outlined in this agreement, and they will remain in force even if
I cease to have an association with UHN.
I also understand that should any of these conditions be breached, I may be subject to corrective action up to and
including termination of employment, loss of privileges, termination of a contract, or similar action appropriate to my
association with UHN.
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Name (print)
Signature
Name of Witness (print)
Signature
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Date
Form D-3236 (29/06/2007)
3/16/2016
PGME UHN Registration Form – 2012/13