Canadian Council on Podiatric Medical Education

Application for Provisional Approval of Residencies in Podiatric Medicine

Application

Podiatric Medicine and Surgery Residency Application for Provisional Approval

This application and supporting documentation must be submitted prior to activation of the residency, at least 9–12 months before the anticipated starting date. RRC and the CCPME require that the program’s director is the individual responsible for submitting all materials to the CCPME related to all application, on-site evaluation, and approval processes. The entire review process for a residency requesting approval may require a period of 12 months from the time an application is received in the office of the Canadian Council on Podiatric Medical Education until the CCPME takes an approval action.

Please submit the application and supporting documents to the CCPME office on two flash drives. Each flash drive is to include this completed form and the documentation in response to questions 9–11 pages 15–16 (supplemental materials) in PDF format, as a single bookmarked continuous document. Hand-written responses and hard copy documentation will not be accepted.

The $1,500 application fee, made payable to the Canadian Council on Podiatric Medical Education, must accompany the application. The application will not be processed until the sponsoring institution submits all required materials, including the application fee.

1. Sponsoring Institution Information
Address *
Address
Phone *
Phone
Fax
Fax
http://
Does the sponsoring institution also have internships or residency programs other than in podiatric medicine & surgery? *
2. Co-sponsoring Institution Information (if applicable)
Address
Address
Phone
Phone
Fax
Fax
http://
3. Program Director Information
Program Director Name *
Program Director Name
Address *
Address
Phone *
Phone
Fax *
Fax
Mobile *
Mobile
4. Administration – List the names and email addresses of persons holding the following staff positions (include professional designations where applicable, e.g. DPM or MD)
Chief Administrative Officer *
Chief Administrative Officer
Designated Institutional Official
Designated Institutional Official
Chief of Podiatric Staff *
Chief of Podiatric Staff
Chief of Medical Staff *
Chief of Medical Staff
Director of Graduate Medical Education
Director of Graduate Medical Education
Chief of Surgical Staff
Chief of Surgical Staff
5. PROGRAM INFORMATION (as defined in the CCPME 320)
Is the resident required to be licensed? *
1st/2nd/3rd/4th
eg. July 1 - June 30
1st/2nd/3rd/4th
6. The following information about the volume of patient care activity should be based on the 12-month period prior to submission of the application. The number of procedures is to include those performed at all facilities utilized by the sponsoring institution (including the sponsor). For secondary institutions or other facilities used, appropriately executed affiliation agreements must exist (and be submitted) to be included in the number of procedures column.
7. Statistics
The statistics below cover the period from *
The statistics below cover the period from
To *
To
Category 1: Digital Surgery (Description (code number))
Enter number of procedures in the box
Category 2: First Ray Surgery (Description (code number))
Category 2: First Ray Surgery - Hallux Limitus (Description (code number))
Category 2: First Ray Surgery - Other First Ray (Description (code number))
Category 3: other soft tissue foot surgery (Description (code number))
CATEGORY 4: OTHER OSSEOUS FOOT SURGERY (Description (code number))
CATEGORY 5: RECONSTRUCTIVE REARFOOT AND ANKLE SURGERY - ELECTIVE SOFT TISSUE (Description (code number))
Can be zero if only a PMSR residency application
CATEGORY 5: RECONSTRUCTIVE REARFOOT AND ANKLE SURGERY - ELECTIVE OSSEOUS (Description (code number))
Can be zero if only a PMSR residency application
CATEGORY 5: RECONSTRUCTIVE REARFOOT AND ANKLE SURGERY - NON-ELECTIVE SOFT TISSUE (Description (code number))
Can be zero if only a PMSR residency application
CATEGORY 5: RECONSTRUCTIVE REARFOOT AND ANKLE SURGERY - NON-ELECTIVE OSSEOUS (Description (code number))
Can be zero if only a PMSR residency application
8. RESIDENCY POLICIES
SUPPLEMENTAL MATERIALS
The following items must be submitted on each flash drive (see page 1 of the application). Please refer to the referenced requirements in CCPME 320, Standards and Requirements for Approval of Podiatric Medicine and Surgery Residencies, for further information specific to each required document.
9. Sponsor and Affiliation Agreements: Please provide the following information for the sponsoring institution, including the sponsor and co-sponsor (if applicable), and each affiliated training site (i.e. hospital, surgery centre, private office), For each institution identified, provide copies of accreditation documents and copies of executed affiliation agreements between the sponsoring institution and the affiliates: (Name, City/Province, Accredited by, Percentage of training, Date Affiliation Signed / Effective Date.)
10. Standard 3 - Policies Affecting the Resident
a. Sample copy of the contract or letter of appointment between the sponsoring institution(s) and the resident.
(requirements 3.8 and 3.9)
b. Residency manual that will be distributed at the beginning of the program to residents, faculty and administrative staff involved in the residency. The manual must include at minimum the following components (requirement 3.10):
a) The mechanism of appeal b) The remediation methods established to address instances of unsatisfactory resident performance c) The rules and regulations for the conduct of the resident d) Rotations and competencies specific to each rotation (requirements 6.1 and 6.4) e) Training schedule for the duration of the program. The schedule must relate to the institutions and facilities listed in response to question #6 and to the rotations listed in response to item (d) above. The schedule must also document that the time spent in the rotations in infectious disease plus internal medicine and / or family medicine plus two medical subspecialities is equivalent to a minimum of three full-time months of training (requirement 6.3) f) Schedule of didactic activities (requirement 6.7) g) Journal review schedule (requirement 6.8) h) Assessment documents for all rotations. Assessment documents must identify the rotation, duration and include lines for the dates and signatures of the faculty, resident and program director (requirement 7.2)
c. Certificate, or sample certificate, to be awarded to the resident upon completion of training. (requirement 3.11)
11. Standard 5 - Program Director and Faculty
a. Curriculum vitae of the program director and a statement providing evidence that he / she possesses appropriate clinical, administrative and teaching qualifications suitable for implementing the residency. (requirement 5.2)
b. List of podiatric medical faculty actively involved in the program with educational and professional qualifications of each. For each staff member, list only the name, degree and affiliations with certifying and professional organizations (i.e. ABPM, ABFAS). Additionally, identify which podiatric faculty, if any, are affiliated with other CCPME approved podiatric residency programs. If a faculty member is not certified by a board recognized by the CCPME, please describe the specialized qualifications possessed by this individual that make him / her qualified in the subject matter for which he / she is responsible (requirements 5.5 and 5.6)
c. List of non-podiatric medical faculty involved in the program with educational and professional qualifications of each. For each staff member, list only the name, degree (MD, DO, PhD, etc.) and affiliations with certifying and professional organizations. (requirement 5.6)
Completing this form, the chief administrative officer(s) and the program director confirm the commitment of the institution(s) in providing podiatric residency training.
A typed name in the fields below will constitute a signature.
Chief Administrative Officer *
Chief Administrative Officer
Chief Administrative Officer of co-sponsoring institution, (if applicable)
Chief Administrative Officer of co-sponsoring institution, (if applicable)
Program Director *
Program Director
Date *
Date