locum information for the terrace bay/schreiber region

The McCausland Hospital
LOCUM INFORMATION FOR THE
TERRACE BAY/SCHREIBER REGION
“Vacation While You Work”
Aguasabon Medical Centre
J.E. Stokes Medical Centre
For More Information, Please Contact:
Suzanne Black, Administrator
Debbie Roen, Officer Manager
Aguasabon Medical Centre
J.E. Stokes Medical Centre
Terrace Bay, ON P0T 2W0
Schreiber, ON P0T 2W0
Phone: (807) 825-3236
Phone: (807) 824-2934, x 227
Fax: (807) 825-3239
Fax: (807) 824-2758
Email: [email protected]
Email: [email protected]
Aguasabon Golf Course
Casque Isles Hiking Trail
Battle Island Lighthouse
“LOCUMS ARE ALWAYS WELCOME”
GENERAL LOCUM INFORMATION
Locums are always welcome and interested physicians should contact either clinic to establish a
date that is accommodating. The Rural Family Medicine Locum Program will reimburse most, if
not all, travel and accommodation expenses. Locums are provided access to a high end furnished
house (if available) and a liaison from the Family Health Team or clinics will serve as a resource
person. There are two sites to choose from with one being in Terrace Bay within the
McCausland Hospital at the Aguasabon Medical Centre and another at the J.E. Stokes Medical
Centre in Schreiber. Regular office hours are from 9:00am to 4:00pm. The volume of patients
seen in the clinics varies, but is generally between 15 and 20 patients a day.
Locums may take as little or as much on-call coverage as they wish. On-call is usually homecall and quiet with knowledgeable triage nurses.
We will start all the paperwork!
All we need is your NAME, ADDRESS and TELEPHONE NUMBER!
Other information such as your hobbies, interests or what you would like to do while you are
visiting will help us organize a locum you will never forget!
FEEL FREE TO CONTACT SUZANNE BLACK OR
DEBBIE ROEN FOR MORE INFORMATION!
REIMBURSEMENT
Clinic
 $800/day
 PLUS $100/day (on RIO Score)
On-call (on top of clinic pay)
 $1,173 per week day
 $1,954 per holiday or weekend day
ACCOMMODATIONS
A fully furnished locum house is available in Terrace Bay within a 2 minute drive to the hospital
or accommodations can be set up at a local hotel or bed & breakfast with the cost being
reimbursed by the Rural Family Medicine Locum Program through Health Force Ontario.
TRAVEL
Travel expenses within Ontario are fully reimbursed; please refer to attached guidelines.
Or visit the Health Force Ontario Rural Family Medicine Locum Program website.
(http://www.healthforceontario.ca/Jobs/OntarioPhysicianLocumPrograms/RuralFamilyMedicine
LocumProgram.aspx).
REGIONAL HEALTHCARE ORGANIZATIONS
NORTH SHORE FAMILY HEALTH TEAM
The North Shore Family Health Team (NSFHT) was established in 2006 and includes the
Aguasabon Medical Centre in Terrace Bay and the JE Stokes Medical Centre in Schreiber. The
Team has an allotment by the Ministry of Health for four full-time physicians. It currently has a
full complement of four physicians for the catchment area of 3,500 residents.
Our Friendly North Shore Family Health Team
The North Shore Family Health Team shares the following professionals:
Healthcare Professionals
 Susan Fairservice - Nurse Practitioner
 Lindy Coughlin – Registered Practical Nurse
 Mary Lynn Dingwell - Social Worker
 Andrea Kennedy - Dietician
Administration & Office Staff
 Beverley Turpin – Administrator
 Jessica Kruger – Administrative Support
 Suzanne Black – Aguasabon Office Manager
 Debbie Roen – J.E. Stokes Office Manager
 Office Staff – Alison McLaughlin, Janis
Prager, and Chantal Ryan
The Family Health Team's mission is to increase
the level of collaborative patient care and
improve the management of health and social
well being of persons in our communities. The
NSFHT aims to provide ongoing health
promotions and illness strategies in coordination
with other health care services.
J.E. Stokes Medical Centre
AGUASABON MEDICAL CENTRE AND J.E. STOKES MEDICAL CENTRE
The Aguasabon Medical Centre is located within McCausland Hospital in Terrace Bay and the
J.E. Stoke Medical Centre is located in Schreiber on Scotia Street. Both clinics are fully
computerized with Electronic Medical Records and PACS (imaging). There is also access to the
regional hospital database including imaging, specialist consultations, and other investigations.
One of the Aguasabon Medical Centre Exam Rooms
Both clinics have friendly, professional administrative staff and 2 to 3 exam rooms per physician.
When on-call, physicians enjoy home-based call that is usually quiet. Excellent triage and
nursing staff allow most issues to be addressed over the phone. Regular office hours for the
clinics are from 9:00am to 4:00pm Mon – Thurs and 9:00am to 1:00on on Fridays.
HEALTHCARE ADMINISTRATION
The main healthcare facility in the area is the McCausland Hospital, which is centrally located in
Terrace Bay and situated overlooking the shores of Lake Superior. It is a fully accredited 23-bed
community hospital with the attached 22 bed Wilkes Terrace long-term care facility. The
McCausland Hospital has a staff of 90 employees with 51 full-time equivalents and serves a
population of approximately 3,500 residents from the communities of Terrace Bay, Schreiber,
Rossport, Jackfish and the small First Nation of Plays Plat. The tertiary care facility for the
region is the Thunder Bay Regional Health Sciences Centre, which is 215 kms away.
Physiotherapy Services Being Offered
Staff Taking A Short Coffee Break
Some of the hospital services include:
 Computed radiology, ultrasound, cardiac
stress testing, and regional PACS
 Full laboratory services
 13 chronic and 10 acute care beds
 Emergency room with 5 patient areas
including a trauma room & cast room
 Visiting specialist clinics including
Cardiology, Orthopaedics & Oncology
 Physiotherapy
 Diabetes Education & Dietary Counselling
 Chemotherapy, Day Surgery, & Tele-health
Laboratory Services
Some of the related community services include:
 Dentistry
 Optometry (in Marathon)
 Chiropractic Services
 CCAC & Home Care
 Mental Health
 Public Health
 Speech Therapy
 Handy Transit
 Meals on Wheels
View from A Hospital Patient Room!
Ultrasound Services
THUNDER BAY REGIONAL HEALTH SCIENCES CENTRE
The Thunder Bay Regional Health Sciences Centre is a state-of-the-art acute care facility serving
the healthcare needs of people living in Thunder Bay and Northwestern Ontario. There are 375
acute care beds. Diagnostic Imaging uses Picture Archival Computer Systems to record the
images from the MRI, 16 and 10 slice CT Scanners and simulators, and other DI equipment
which permits easy transportation of files among radiologists and specialists anywhere so they
may view and assess images. The ability to
store and move the data of a patient from an
Electronic Medical Record makes the region’s
hospitals of Northwestern Ontario a virtual
library whereby physicians and “need to know”
care providers can assist with patient care in an
instant. The Emergency Department is one of
the busiest in the country with approximately
95,000 annual visits. The OR suite containing
12 theatres also includes a High-dose
Brachytherapy room for special Cancer Care
procedures. The 28 bed Post Anesthetic
Recovery Unit has full med gas services as does
the 40 bed Day Surgery Recovery area.
LOCUM PHYSICIAN’S CHECKLIST
In preparation for your locum in the Terrace Bay and Schreiber region, please complete the
following steps:
1. E-mail or fax your clinic contact person the following information:
a. Your full name
b. Permanent address and phone number
c. Current contact information: phone number, fax, e-mail, mailing address
d. CPSO #, OHIP #, WSIB #
e. Start and End Dates of Locum
f. Dates of requested days on-call that you would like to work
2. Notify your clinic contact person of the following:
a. Finalized travel plans and arrival/departure dates/times
b. Whether you plan on using the locum apartment or other accommodations
c. Special needs at your accommodations prior to your arrival (ex. Groceries). Please
note that most stores are open from 9:00am-5:00pm and are closed on Sundays
3. Complete attached documentation – hospital privileges and HIMS new provider form and fax
or e-mail back to clinic contact person
4. Notify your clinic contact person if you would be interested in the following activities:
 Fitness or Weight Room
 Golfing
 Boat Charter
 Bowling
 Kayaking
 Squash, Racquetball or Tennis Courts
 Hiking
 Downhill or Cross Country Skiing
 Jogging or Walking
 Crafts shopping
5. Please make specific arrangements with your clinic contact person with regards to where to
go when you first arrive for you locum.
* On the date of your arrival or your first working day (whichever you prefer), you will be given
a tour of the various hospital departments and the clinic from your clinic contact person. A tour
of the communities, if desired, by a local representative will also be arranged. Within the locum
apartment is information on regional tourism attractions and restaurants. You will also be given
a cellular phone to use during your stay and keys to the apartment.
For More Information, Please Contact Your Clinic Contact Person:
Terrace Bay
Suzanne Black, Administrator
Aguasabon Medical Centre
Phone: (807) 825-3236
Fax: (807) 825-3239
Email: [email protected]
Schreiber
Beverley Turpin, Administrator
J.E. Stokes Medical Centre
Phone: (807) 824-2934, x 230
Fax: (807) 824-2758
Email: [email protected]
PRIVATE LOCUM HOUSE FOR RENT – 14 SOUTHRIDGE CRESCENT, TERRACE BAY






To request house, please ask clinic staff
Master Bedroom
Kitchen
1091 sq ft house with updated décor, WIFI
4 bedrooms, 2 bathrooms, detached garage,
Forced air oil furnace, built in 1979
The clinic will be your contact point and answer
any questions you may have during your stay
Fully furnished with cutlery, linen, etc
Pets are not allowed with this house
Backyard Patio
Master Bathroom
Downstairs Rec Room with 52” Television
Main Floor Living Room
Downstairs Bedroom
Downstairs Bathroom
Main Floor Dining Room
Upstairs Bedroom
Downstairs Laundry
Locum Physician
Expense Form
Rural Family Medicine Locum Program
Assignment No.:
(See reverse for claiming guidelines)
Locum Physician Name: ________________________________________________________ CPSO No.: __________________________
Pay to (name): ____________________________________________________________Telephone No.: __________________________
Pay to (address ): _______________________________________________________________ Fax No.: __________________________
___________________________________________________________________________ Postal Code: __________________________
E-mail: _______________________________________________________________________________
Rural Family Physician Name: __________________________________________________ Community: __________________________
Start Date: (yy/mm/dd) _____________________ End Date: (yy/mm/dd) _____________________ Assignment Length: _________ days
Stipend
FFS & FHGs
FHTs & FHNs & FHOs
RNPGAs
Stipend Premiums
____ Days @ $600/day
____ Days @ $700/day
____ Days @ $800/day
RIO < 60
RIO 60 to 75
RIO > 75
none
$50/day
$100/day
Amount
Amount
Claimed
Paid
_________ __________
_________ __________
_________ __________
________
________
Discrepancy (Explain)
__________
__________
Stipend Total
Travel
Travel
Stipend
Distance to Assignment
From Assignment
During Assignment
TOTAL
______ kms
______ kms
______ kms
______ kms @ $0.44
_________ __________
_________ __________
_________ __________
_________ __________
Car Rental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Taxi/Parking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Economy Fare to and from assignment:
airfare
bus
train
Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
_________ __________
_________ __________
Between 2 & 4 hours travel
Greater than 4 hours travel
_________ __________
_________ __________
_________ __________
$300/day
$500/day placement ≥ 4 days
$300/day placement < 4 days
_________ __________
_________ __________
Accommodation (maximum up to $120/night in a hotel/motel)
Total # of nights claimed _______
Travel and Accommodation Total
GRAND TOTAL
________
All original receipts provided — Please photocopy your completed expense form and original receipts for your records
Physician Comments: _____________________________________________________________________________________
Locum Physician Signature: ______________________________________ Date: ___________________________
_________________________________________ Date: _____________________ Amount Paid: $ ________________________
HealthForceOntario Marketing and Recruitment Agency
Rural Family Medicine Locum Program
285 Victoria St., 7th Floor
Toronto, ON M5B 1W1
www.HealthForceOntario.ca
Tel.: 416-314-4409
Fax: 1-866-535-2694
North America: 1-800-596-4046
Email: [email protected]
This program is administered by the HealthForceOntario
Marketing and Recruitment Agency with funding provided
by the Government of Ontario
Notice of Collection: HealthForceOntario Marketing and Recruitment Agency (HFO MRA) collects your personal information under the authority of the Development Corporations Act, Ontario Regulation 249/07, Section 3. The personal information you provide to us during
our interactions is necessary for HFO MRA to provide you with career assistance and/or assist you with your employment search. HFO MRA may use the information to contact you to discuss issues related to practising in Ontario and tell you about health care career and job
opportunities. HFO MRA may share your personal information with appropriate agencies and professional bodies, recruiters, health care employers, the Ministry of Health and Long Term Care, and/or community representatives for the purpose of helping you explore job
opportunities and careers in Ontario. HFO MRA may also use this information to research and evaluate our recruitment and career assistance activities.
If you require further information about this please contact our information coordiantor at: HealthForceOntario Marketing and Recruitment Agency, 285 Victoria St., 7th Floor, Toronto, Ontario M5B 1W1. Tel: 416-314-4409 or 1-800-596-4046, Fax: 416-598-5968
Ontario Physician Locum Programs, Rural Family Medicine Locum Program
Claiming Guidelines for Locum Physicians
To receive funding a physician must have received pre approval from HFO MRA, prior to commencing the assignment. The rural physician,
locum and HFO MRA will sign a contract before the assignment starts.
Expense forms and evaluations must be received within 30 days of completion of the assignment. Expense forms must also be signed by the
locum and accompanied by the original receipts for all expenses claimed.
Only one assignment per expense form is to be used. Each expense form will be processed within four weeks.
STIPEND
Rural and Northern Physician Group
Family Health Network and Family Health Organizations
Fee for Service
$800/day (maximum of 37 days per year)
$700/day (maximum of 21 days per year)
$600/day (maximum of 21 days per year)
PREMIUMS ON STIPEND
RIO less than 60
RIO greater than or equal to 60, and less than 75
RIO greater than or equal to 75
none
$50/day
$100/day
TRAVEL STIPEND (maximum of 2 days)
Less than 2 hours of travel
2 to 4 hours of travel
Greater than 4 hours of travel
none
$300/day
$500 for a placement 4 days or longer
$300 for less than 4 days
Travel stipend cannot be claimed on days which are included as part of the assignment.
TRAVEL: Personal Vehicle: Most direct route to and from the assignment will be fully reimbursed at a rate of 0.44¢ per km in Ontario.
Distance associated with the provision of medical services in the community during the assignment will be reimbursed at the same rate.
Airfare/Bus/Train: Economy class travel to and from the assignment will be fully reimbursed in Ontario. Upgrades to either first or business class, and travel insurance are not eligible for reimbursement. Original receipts (or last page of the airline ticket) must accompany the
claim.
Rental Car: The cost of an economy rental car for the duration of the assignment will be covered when required. Original receipts must be
included. Where the rental period extends beyond the assignment dates, the reimbursement will be adjusted accordingly. During winter
conditions (November-April) the cost of a ‘four wheel‘ drive vehicle will be allowed (if available) for the duration of the assignment.
TAXI/PARKING: Charges for taxis and parking at point of departure will be reimbursed. Original receipts must be provided.
TRAVEL OUTSIDE OF ONTARIO: When travelling from outside of Ontario to an assignment only costs associated with travel within Ontario
will be reimbursed, and will be calculated from the nearest point of entry to the assignment location.
ACCOMMODATION: Single occupancy accommodation up to $120 maximum/night during peak season in a hotel/motel for the duration
of the assignment. Please negotiate the best rate possible. The original receipt, in the locum physicians’ name must accompany the expense
claim. Movies, mini-bar, telephone, meals and other miscellaneous charges will not be reimbursed. When required, accommodation for one
night before and one night after the assignment will be allowed. We do not pay the costs when you stay in a physician’s home.
QUESTIONS: Any questions regarding how to complete the expense form or how to obtain additional forms should be directed to the
Operations Coordinator at 1-800-596-4046 extension 4 or [email protected]. The HFO MRA fax number is 1-866-535-2694.
Submit expense claims to:
Operations Coordinator, Rural Family Medicine Locum Program
285 Victoria Street, 7th floor, Toronto M5B 1W1
HIMS Provider Dictionary
New Provider Request Form / Provider Change Request Form
REQUESTING FACILITY:
MCCA
PERSON FILLING OUT FORM:
Cheryl Kostecki
PROVIDER INFO
Surname:
First Name:
OHIP Billing #:
Licence (CPSO) #:
http://www.cpso.on.ca/docsearch/
(i.e. Family MD, Surgeon, Nurse Practitioner, Orthopedic)
***Please specify if physician is a LOCUM***
Provider Type:
Provider Group:
PRIVILEGES
COURTESY PRIVILEGES
On Staff:
Admitting:
Ordering:
YES
YES
Yes
TBRHSC Ordering: YES
MAILING ADDRESS
PERMANENT ADDRESS (LOCUMS)
Aguasabon Medical Clinic
P.O. BOX 819
TERRACE BAY, Ontario P0T 2W0
Phone:
807-825-3235
Phone:
Office Fax:
807-825-3239
Office Fax:
Pager:
Pager:
Email:
Email:
REPORT DISTRIBUTION - Please indicate how provider would like to receive reports from your hospital
F=Auto Fax
P= Print
N=No Reports
POI = Physician Office Interface
HR: POI
DI:
POI
LAB: POI
* If POI is chosen, please indicate the Clinic Name:
**If Auto Faxing is chosen, please indicate a confirmed, confidential fax number: 807-825-3239
* The Clinic must be signed up for POI with TBRHSC Information Systems
**This number is used for auto faxing only. It is specific to reports generated at your site. It may be different from the general office fax and/or the auto faxing
number assigned to other sites.
AUTHORIZATION
___________________________________________________
Signature of Staff Authorizing Request &Verifying Credentials
Suzanne Bouchard
_________________________________________
Print Name
FAX or EMAIL Completed Forms to the SERVICE DESK @
807-684-7506 / [email protected]
NORTHWEST REGIONAL APPLICATION FOR APPOINTMENT
(This form to be typewritten or printed)
PRIMARY ORGANIZATION: ___________________________________________________
STAFF STATUS BEING APPLIED FOR: ________________________________________
DEPARTMENT: _________________________________________________________
ALTERNATE DEPARTMENT/PROGRAM (IF APPLICABLE): ___________________________
REGIONAL STAFF (Ordering of Diagnostic Tests Only)
Please
(check) each institution where you wish to apply.
(These privileges are dependent on privileges being granted at your primary organization)












Atikokan General Hospital (Atikokan, Ontario)
Dryden Regional Health Centre (Dryden, Ontario)
Geraldton District Hospital (Geraldton, Ontario)
McCausland Hospital (Terrace Bay, Ontario)
Manitouwadge Health Centre (Manitouwadge, Ontario)
Nipigon District Memorial (Nipigon, Ontario)
Red Lake Margaret Cochenour Memorial Hospital (Red Lake, Ontario)
Riverside Health Care Facilities (Fort Frances, Ontario)
Sioux Lookout Meno Ya Win Health Centre (Sioux Lookout, Ontario)
St. Joseph’s Care Group (Thunder Bay, Ontario)
Thunder Bay Regional Health Sciences Centre (Thunder Bay, Ontario)
Wilson Memorial General Hospital (Marathon, Ontario
I agree to abide by the obligations outlined in the Northwest Regional Appointment and Credentialing
Policy and Procedure and to sharing of data/information with each organization where I apply for
privileges.
Date:
Signature:
NAME IN FULL:
Salutation
First Name
Middle Name
Surname
DATE AND PLACE OF BIRTH:
Date (dd/mm/yr)
City of Birth
CITIZENSHIP:
LANGUAGES:
1
Country of Birth
NORTHWEST REGIONAL APPLICATION FOR APPOINTMENT
GENDER :  Female  Male
ADDRESS:
City
Province
Postal Code
Telephone
E-Mail Address
Other: Mobile/Cell/Blackberry
Pager Number
Fax Number
CURRENT PHOTO ATTACHED: □ Yes □ No
LICENCING COLLEGE:
Membership Certificate Number:
(ie Physicians & Surgeons of Ontario, Midwives, Dentistry, Nurses)
 RN-EC: Consultative Physician Name (s)
(must include verification - signed correspondence from consultative physician)
Registration Class: ________________________________ Date of Expiry:________________
ie Physicians: Independent Practice, Restricted; Midwives: General, General with Conditions,
Restricted; Dentists: General, Academic Specialty
CURRENT LIABILITY INSURANCE NUMBER:
TYPE OF WORK CODE:
(Physicians)
NAME OF INSURER:
(Attach Certificate(s)
OHIP BILLING NUMBER:
SPECIALTY CODE
2
NORTHWEST REGIONAL APPLICATION FOR APPOINTMENT
6 Digits
2 Digits
SIGNATURE:
(I authorize my OHIP Physician Number to be released to other professional/privileged staff requiring it for
billing purposes)
PROFESSIONAL DESIGNATION:
(ie CCFP, FRCP)
MEDICAL SCHOOL DIPLOMA (NAME OF UNIVERSITY /PROFESSIONAL SCHOOL AND YEAR OF GRADUATION):
Attach Certificate(s)
SPECIALIST CERTIFICATE (IE ROYAL COLLEGE):
(Attach Certificate(s)
CURRICULUM VITAE - Must include the following:
 Non-University Degrees
 Post-Graduate Training
 Practice Experience
 Publications
 Professional Societies & Association Membership
 Hospital Staff Appointments
 Procedural Privileges held in other Institutions
If above information is not included on CV please attach list.
REFERENCES: □ Previously provided on the “Request for Application” form
Names and contact information (address, fax, email) of three (3) references from the last organization in
which the applicant trained or held an appointment.
References should include:
(i)
Administrator and Chief of Staff/Chair of the MAC of the last hospital
where the Applicant held privileges or received training;
(ii)
Departmental colleagues from the last hospital or institution in which the
Applicant held an appointment or received training; and
3
NORTHWEST REGIONAL APPLICATION FOR APPOINTMENT
(iii)
Service Director or Head of Training Program if enrolled in a Graduate
Training Program within the past three years;
1.
2.
3.
Have you practiced in another part of Canada? Yes
If yes, where and when?
No
Have you participated regularly in programs for continuing medical education or self evaluation?
Yes No
Do you currently suffer from any physical condition, psychiatric conditions, impairment, disease or
illnesses that would impact your ability to fulfill and discharge the privileges you have requested?
Yes No
If yes, please provide details.
Have you had any voluntary/involuntary alterations, restrictions or limitations on your licence to practice?
Yes No
If yes, please provide details.
Have you been convicted of any criminal offense? Yes
If yes, describe the offence.
No
Have you had any past civil or professional liability claims including settlements or final judgments? Yes
No
If yes, provide details.
a)
b)
I am the person named in this application and that the given information is true and accurate to
the best of my knowledge.
I have read the requirements set out in the Northwest Regional Appointment and Credentialing
Policy and Procedure, By-laws and Rules of the Hospitals, the General Regulations under the
Public Hospitals Act of Ontario and the code of ethics of the Canadian Medical Association/
College of Midwives of Ontario/ Canadian Dental Association/ College of Nurses of Ontario, and if
appointed to the staff, in consideration of such appointment, agree and undertake to conform to
and to govern myself in accordance with these. I further agree to conform to and to be bound by
any amendments or additions that may from time to time be made to the above mentioned,
Northwest Regional Appointment and Credentialing Policy and Procedure, By-laws and Rules,
4
NORTHWEST REGIONAL APPLICATION FOR APPOINTMENT
c)
Date
General Regulations under the Act and code of ethics of the Canadian Medical Association/
College of Midwives of Ontario/ Canadian Dental Association/ College of Nurses of Ontario. I
agree to perform only those procedural privileges for which I have the knowledge/skill and ability
to perform and which fall within my scope of practice.
I authorize the Ontario College of Physicians and Surgeons/ College of Midwives of Ontario/
Royal College of Dental Surgeons of Ontario/ College of Nurses of Ontario, to provide any
information as to whether:
i)
any disciplinary action may have been taken concerning my conduct;
ii)
there is, at present, any inquiry into my conduct;
iii)
any other hospital has curtailed or canceled my privileges because of incompetence,
negligence of any act of professional misconduct.
Applicant’s Signature
Witness
Please ensure information required below has been included:
 Graduation Diploma (Professional School/University)
 Specialist Certificate (if applicable)
 Current Membership Certificate (Licence to Practice in Ontario)
 Current Liability Insurance Certificate
 OHIP Physician Number (if available)
 Curriculum vitae
 Current photograph
Return completed form to Primary Institution
REPORT OF THE DIRECTOR OR PROGRAM LEAD (IF APPLICABLE):
Date:
Signature:
REPORT OF THE CHIEF OF ALTERNATE DEPARTMENT (IF APPLICABLE):
5
NORTHWEST REGIONAL APPLICATION FOR APPOINTMENT
Date:
REPORT OF THE CHIEF OF
Signature:
DEPARTMENT OR CHIEF OF STAFF:
Date:
Signature:
6
REGIONAL IMMUNIZATION REQUIREMENTS
PRE APPOINTMENT HEALTH FORM FOR ALL PRIVILEGED/PROFESSIONAL STAFF
The Communicable Disease Surveillance Protocols for Ontario Hospitals, developed by the Ontario Hospital Association and the Ontario
Medical Association, approved by the Ministry of Health and Long Term Care, and endorsed by the Canadian Medical Protective Association,
in accordance with Regulation 965/90 Section 4 of the Public Hospitals Act, applies to all “persons carrying out activities in the hospital, and
continuing surveillance based on risk” ; and requires known immune status on all health care workers, including physicians, dentists
midwives , nurse practitioners and special professional staff .
A. PERSONAL INFORMATION
Last Name
First Name
Date of Birth
Designation
DD/MM/YEAR
Address
Apt. #
For Office Use Only
Date Accepted as Complete
City
Province
Local Tel.
Postal Code
Cell #
____________
DD/MM/YEAR
Email#
B. POLICY FOR PROFESSIONAL HEALTH CARE WORKERS
Workers in Health Care have an obligation to protect patients and themselves from infection that can be transmitted within
the hospital setting. Immunization is an important tool in preventing the transmission of infections and assists in
safeguarding the health of the workers:
1.
2.
3.
The Public Hospital Act has mandated immunization /testing requirements for all workers in Hospitals.
A Hospital has the right to refuse access to those who do not meet their immunization/testing requirements.
Failure to submit a signed and correctly completed immunization form may result in being withheld from hospital
work.
It is the professional health care workers responsibility to ensure the following:
1.
The form is complete, legible and signed. Copies can be made for personal records.
C. IMMUNIZATION
C.1
Tetanus/Diphtheria (Due every 10 years)
Date of last immunization ____________________
Pertussis
Date of last immunization ____________________
Note: A single dose diphtheria-acellular pertussis vaccine (Tdap) must be previously received as an adolescent or adult.
Tetanus-diptheria (Td) dose must be documented within the last 10 years.
C.2
Past history of Varicella (Chicken Pox) or Shingles:
( ) Yes No ( )
If yes, proceed to C.3. If no, complete the following questions.
Year___________________
Laboratory evidence of immunity status is required : Results __________________
Varicella vaccination (Highly recommended if history of disease is unknown)
st
1 vaccination:
2
nd
vaccination:
Date: __________________________
Date : _________________________
7
Date ___________
REGIONAL IMMUNIZATION REQUIREMENTS
C.3
MMR (Measles, Mumps, and Rubella):
Documented 2 doses of MMR vaccine given at least 4 weeks apart, on or after the first birthday if born in 1970 or later.
st
nd
Initial vaccination dates: 1 : _____________________________ 2 : ______________________________
Possible additional Booster date: __________________________
MMR evidence of immunity is required
Measles :Results __________________
Date ___________
Mumps : Results __________________
Date ___________
Rubella : Results __________________
Date ___________
C.4
Hepatitis B:
st
1 vaccination: Date: _____________________________
nd
2
vaccination: Date: _____________________________
rd
3 vaccination: Date: _____________________________
Hepatitis B evidence of immunity is required
Results __________________
Date ___________
C.5
Tuberculin Skin Test (TST) OR Mantoux Test Requirement. All professional staff require proof of a past two-step TST
and any TST performed within the last 12 months
All professional staff require a history
Prior history of BCG vaccination:  No
 Yes: Year __________
Prior history of TB infection:
 No
 Yes: Year __________
Treatment :  Yes  No
Note: A history of a BCG is not a contraindication to TST unless there is a history of a strong positive TST.
Two Step Tb skin test
Test #1 given on (date): _________________________ Result (mm of induration): ____________________
Test #2
given on (date): _________________________ Result (mm of induration): ____________________
One-step Tb skin test most recent date
given on (date): ______________________ Result (mm of induration) ___________
D. FIT TESTING
Fit Testing is recommended for anyone who has a job function that would require them to wear a N95 mask. The N95 mask is currently
worn as a basic mask for respiratory isolation and routine respiratory precautions in ER, ICU, and for entering the room of a suspect or
confirmed TB patient.
Have you been fit tested within the last two years as per CSA Standard Z94.4-02
□ Yes If yes, indicate date & type of mask:
Date:____________________
Year________________________ Mask Type _____________________________
E. SIGNATURE
Full Name:
Signature:
8
REGIONAL IMMUNIZATION REQUIREMENTS
References: Public Hospitals Act, Regulation 965, Bylaw 4d (i-v) and 4e, pR5.2;
Communicable Disease Surveillance Protocols for Ontario Hospitals
9
Pre Placement/Credentialing Form#1 2011
HWHA Confidentiality and Accountability Form
NORTHWEST HEALTH ALLIANCE
REGIONAL HOSPITALS
PROTECTION OF CONFIDENTIAL INFORMATION AND ACCOUNTABILITY
I, __________________________________, understand that I am responsible for the protection of the
confidential nature of information concerning patients/clients, corporate personnel and other confidential types
of corporate information. I will respect the confidential nature of all information.
I will exercise all reasonable care and caution in protecting printed or written confidential information from
casual observation, unauthorized perusal, or other abuse.
I understand that I will not reveal any confidential information, which may come to my knowledge, within or
outside of The Hospitals of the North West Health Alliance unless required in the performance of my normal
duties or expressly authorized by law or by the corporation(s).
I understand that I will not search for, access or divulge any corporate, patient/client information that is not
required in the performance of my duties.
I will not search for or access patient/client information for personal or family use.
To obtain clinical information pertaining to my own medical record, I will contact my physician or contact Health
Records.
I will not leave my session unattended without first suspending or logging off.
Access is limited and strictly confined to information required for the performance of current Hospital duties.
I will ensure that my PASSWORDS are known only to myself, as disclosure could provide opportunities for
unmonitored and unauthorized use. I understand that I am responsible for all access under my PASSWORD
and that I am responsible to always log off or suspend my terminal before leaving it unattended.
Should you feel that your password has been compromised, contact the Help Desk at 1-888-291-9636. Your
old password will be terminated and you will be instructed to initiate a new password.
Non-compliance with any of the above will result in disciplinary action, up to and including dismissal as provided
for in hospital policies and/or loss of privileges from SJGC, TBRHSC or Hospitals within The North West Health
Network.
____________________________________
Signature
_______________________________
Position, Department & Employer
____________________________________
Witness
_______________________________
Date




X





Atikokan General Hospital
Dryden Regional Hospital
Geraldton District Hospital
Manitouwadge General Hospital
McCausland Hospital
Nipigon District Memorial Hospital
Red Lake Margaret Cochenour Hospital
Riverside Health Care
Sioux Lookout Health Centre
Wilson Memorial General Hospital






Employee
Medical Staff
Resident
Medical Student
Student (specify) _________________
Physician’s Clinic/Agency Non-hospital employee
Hydro Bay
Visit www.terracebay.ca/lifestyle for more info and videos
Have questions about Terrace Bay? Email [email protected]
Ontario, Canada
OVERVIEW
Terrace Bay is a beautiful small town of 1,800 people located
at the top of Lake Superior in Northern Ontario. The town has
a proud forestry history and the region is known for a relaxing
pace of life and incredible outdoor experiences. Terrace Bay
has an amazing location directly on the Trans Canada
Highway overlooking Lake Superior and the Slate Islands
Provincial Park. The neighbouring community of Schreiber is
10 minutes away and has another 1,200 residents. Terrace
Bay is a scenic two hour drive from the City of Thunder Bay
which has 110,000 residents.
ECONOMY
Terrace Bay Pulp Inc.
Aerial of Terrace Bay
Terrace Bay has a growing economy that has seen the following
investments in the Community:
 $250 million planned investment 2014-2016 - Aditya Birla Group
 $3 million in 2010/2011 for downtown revitalization
 $2 million in 2010 for renovation of a multi-use facility
 $8 million in 2009-2011 for a 22-bed long-term care facility
 $4.5 million in 2009 for water intake infrastructure
 $2 million in 2009 for a highway commercial development
 $45 million in 2008 for forestry industry energy cogeneration
 $5.5 million in 2007 for a Catholic/French school & daycare
LIFESTYLE
BUSINESS COMMUNITY
Terrace Bay has an ideal lifestyle with access to many
nearby sand beaches and hiking & snowmobile trails.
People are friendly and residents enjoy a relaxing way
of life. Real estate is affordable with average house
prices of $80,000 in 2013. Small town life has almost
no exposure to crime, pollution, or traffic and most
goods and services are within walking distance or
available online.
Terrace Bay has a strong business community with
most goods and services available within a two
minute drive including groceries, pharmacy, eight
restaurants, three gas stations, three motels, Home
Hardware Building Centre, LCBO, post office, car
dealership and other service type businesses.
Visit us at facebook.com/yourterracebay
or follow us on Twitter @YourTerracebay
Terrace Bay Downtown
Ontario, Canada
HEALTHCARE
Terrace Bay has a thriving healthcare
community. McCausland Hospital is a
modern, fully-accredited 45 bed facility
including the Wilkes Terrace Long-Term
Care expansion. Tertiary care is available in
Thunder Bay. Hospital services include: full
laboratory, radiology, cardiac stress testing,
McCausland Hospital
ultrasound, physiotherapy, chemotherapy,
emergency room, ambulance services, day surgery, diabetes education, dietary counseling, tele-health, and
visiting specialist. Related community services include: dentistry, public health, optometry, speech therapy,
mental health, chiropractic services, home care and meals on wheels. The Aguasabon Medical Clinic in
Terrace Bay has a full complement of family physicians and offers same day medical service. The North
Shore Family Health Team provides access to other healthcare professionals including Nurse Practitioner,
Registered Dietitian, Registered Practical Nurse and Registered Social Worker.
EDUCATION
St. Martin Catholic and
École Catholique Franco-Terrace
Terrace Bay has excellent education
options for children, youth and adults.
The Kids Corral Child Care Centre
has drop in and easily accessible
daycare services.
Primary school
education offers small class sizes and
personal instruction through Terrace Bay Public School, St. Martin Catholic and École Catholique FrancoTerrace. Lake Superior High School is a safe, nurturing environment for teenagers with students from Terrace
Bay and nearby Schreiber. The adult learning centre has classes for residents to improve job market skills and
Contact North has a selection of distance education certified programs and degrees. Lakehead University and
Confederation College are two hours away for specialized education, distance learning & training partnerships.
INFRASTRUCTURE
Fishing Lake Superior
Electricity is provided by Hydro One and Heating Oil and Propane is utilized
in the absence of natural gas. Lake Superior is the Municipal water source
and the recently built water treatment plant meets all provincial drinking
water quality standards. Bell Canada is the main telephone provider and
TBayTel is the main cellular provider with digital cellular 4G coverage.
Highspeed Internet is provided by both Shaw Cable and Bell Canada.
TOURISM AND RECREATION
Terrace Bay is the Eastern Gateway to the Lake Superior National Marine
Conservation Area and has numerous attractions including: the Aguasabon
Falls, the Slate Islands, the Dragfest, the Aguasabon Golf Course, Trestle
Ridge Ski Hill, nearby beaches and inland lakes and 3 provincial parks within
45 minutes. The Township runs a modern community centre with a fitness
room, ice arena, racquetball courts, bowling and curling facilities, and track,
soccer, and baseball fields. Tennis courts, an outdoor pool and skateboard
park are also within walking distance. An indoor pool is 45 minutes away at
Marathon, an easy day trip. Terrace Bay has excellent hunting and fishing as
well as public boat launch with access to Lake Superior.
Outdoor Pool in Terrace Bay
Schreiber
Ontario, Canada
www.schreiber.ca
“Engineering Our Small Town Dream”
HISTORY
The Township of Schreiber has a rich history built on its longstanding
relationship with the Canadian Pacific railway. Isbester’s Landing was
originally established in 1883 as a docking area and construction
camp for the railway and the settlement consisted of log cabins and
tents. The Township of Schreiber was officially incorporated as a
township on July 13th, 1901. Schreiber’s ties with the railway were
formally recognized in 1994 with the CPR station receiving a heritage
designation. Today, visitors can view the beautifully restored 1955
Canadian Pacific railway locomotive located in Schreiber’s downtown
Railway Heritage Park.
ECONOMY
Schreiber has a diversified rural economy with strong employment at
Canadian Pacific railway, a healthy operation at nearby AV Terrace Bay
Inc., a growing healthcare sector and a rich service industry catering to
residents and tourists. Affordable real estate is available and the
Township will work with businesses to meet their needs. The town is
strategically located with access to the Trans Canada Highway, Lake
Superior, and railroad infrastructure. The town has a population of 1,200
residents with 1,800 more within a 15 minute drive and approximately
140,000 within 2 hours driving time.
QUALITY OF LIFE
Schreiber has excellent quality of life with access to
nearby beaches and hiking trails, friendly people,
reasonably priced real estate, and a relaxing lifestyle.
The small town feel is free of big city issues like
crime, pollution, and traffic, with goods and services
being easily within walking distance. The Schreiber
Public Library arranges activities for all ages,
including seniors and recreation programming offers
something for everyone.
Schreiber
•
Thunder
Bay •
•
Opportunities for business/economic development
are present in the following areas:
 Industrial type development
 Commercial development
 Energy development
 Highway commercial
 Tourist operators/outfitters
 Resident and tourist service providers
 Information technology services
* Contact the township for additional information
LOCATION
Schreiber is situated in the centre of Canada with
access to major markets within a 1-2 day drive.
Lake Superior
Duluth
BUSINESS OPPORTUNITIES
•
Marquette
Sault Ste
Marie
•
Highway traveling distances (2006 populations):
- Thunder Bay: 211 km, 131 miles. pop. 120,000
- Sault Ste Marie: 497 km, 309 miles, pop. 75,000
- Winnipeg: 887 km, 551 miles, pop. 630,000
- Toronto (GTA): 1,174 km, 729 miles, pop. 5.5 million
- Twin Cities: 759 km, 471 miles, 3.5 million
- Chicago: 1,228 km, 763 miles, 3 million
- Calgary: 2,225 km, 1382 miles, 1 million
Schreiber
Ontario, Canada
Schreiber Beach
HEALTHCARE
Schreiber has an established healthcare community with JE Stokes
Medical/Dental Clinic and nearby McCausland Hospital in Terrace
Bay. McCausland Hospital is a modern, fully-accredited 45 bed
facility including the Wilkes Terrace Long-Term Care expansion.
Tertiary care is available in Thunder Bay. Hospital services include:
full laboratory, radiology, cardiac stress testing, ultrasound,
physiotherapy, chemotherapy, emergency room, ambulance
services, day surgery, diabetes education, dietary counseling, telehealth, and visiting specialist. Related community services include:
dentistry, public health, optometry, speech therapy, mental health,
chiropractic services, home care and meals on wheels.
Municipal Complex
JE Stokes Medical Clinic
EDUCATION
Schreiber has good education options for children, youth and
adults. Daycare is available in Terrace Bay and Schreiber
Public School offers small class sizes and Holy Angels offers
Catholic instruction. Lake Superior High School in Terrace
Bay is a safe and nurturing environment for teenagers. The
Adult Learning Centre provides classes for residents to
improve job market skills and Contact North has a selection of
distance education certified programs and degrees. Lakehead
University and Confederation College are two hours away for
more specialized education and are open to training
partnerships.
INFRASTRUCTURE
Electricity is provided by Hydro One and heating oil
and propane are utilized in the absence of natural
gas. The Township has a modern water and sewage
infrastructure. Bell Canada is the main telephone
provider and TBayTel is the main cellular provider
with electronic switching equipment, linkages to a
fiber optics/digital microwave network and digital
cellular coverage throughout the Township. Bell
Canada and Shaw Cable provide broad-band
internet services.
Please feel free to contact municipal staff at:
Township of Schreiber
Jon Hall, Clerk
204 Alberta Street,
Schreiber, ON P0T 2S0
Office: (807) 824-2711, x225
Fax: (807) 824-3231
[email protected]
Web: www.schreiber.ca
TOURISM AND RECREATION
Schreiber has numerous attractions and activities
including: Schreiber Beach, the Railway Heritage
Museum, Whitesand Lake, the nearby beaches and
inland lakes and 3 provincial parks within 55 minutes.
The Township operates a modern community centre
with an arena, fitness room, and large spaces for
meetings and group exercises. Tennis courts and
track, soccer and baseball fields are available to the
public. The Township has a vast array of hiking,
skiing, and snowmobiling trails and a public boat
launch providing access to Whitesand Lake.
Railway Museum
Locomotive
Youth Hockey
STREET MAP OF SCHREIBER
= J.E. Stokes Medical Centre
STREET MAP OF ROSSPORT
TRAVEL DIRECTIONS
Whether landing at Thunder
Bay International Airport,
Sault Ste. Marie Airport or
by driving, Terrace Bay and
Schreiber are located East
directly on Highway 17,
which is part of the Trans
Canada highway.
For specific driving
directions, please visit
google maps or mapquest or
request directions from the
local healthcare contact
person.
REGIONAL ATTRACTIONS MAP
9
1
2
1 – Rossport Harbour
2 – Battle Island Lighthouse
3 – Schreiber Beach
4 – Worthington Bay
5 – Schreiber Rail Museum
6 – Aguasabon Falls
3
5
4
6
8
7
10
11
7 – Terrace Bay Beach
8 – Aguasabon Golf Course
9 – Terrace Bay Dragfest
10 – Terry Fox Beach
11 – Steel River
THINGS TO DO IN TERRACE BAY, SCHREIBER AND ROSSPORT
Visit the PLAY section of www.terracebayschreiber.ca
for your tourism information needs (and videos)!!!
Attractions:
 Terrace Bay Lighthouse in Simcoe Plaza
 Aguasabon Falls and Gorge
 Aguasabon 9-Hole Golf Course
 52km Casque Isles Hiking Trail
 Terrace Bay Beach
 Schreiber Beach
 Schreiber Rail Museum
 Slate Islands Provincial Park
 Rainbow Falls Provincial Park
 Neys Provincial Park
 Rossport Harbour or Battle Island Lighthouse
 Trestle Ridge Ski Hill
Activities:
 Book a Charter to the Slate Islands, the Steel
River, the Battle Island Lighthouse or for a Day
of Touring the Bays of Lake Superior
 Shop at Simcoe Plaza in Terrace Bay
 Enjoy a Relaxing Day Walking About Rossport
 Listen to the North Shore Singers Choir
 Curling at the Terrace Bay Recreation Centre
 Bowling at the Terrace Bay Recreation Centre
 Play Squash or Racquetball in Terrace Bay
 Play Tennis in either Terrace Bay or Schreiber
 Workout in either Terrace Bay or Schreiber
 Visit a Terrace Bay or Schreiber Playground
 Visit the Terry Fox Beach in Jackfish
 Hike to the Jackfish Ghost Town
 Learn about the Shipwrecks in Lake Superior
 Bike or Rollerblade on a Local Path or Trail
 Go Swimming in an Outdoor Pool or at a Beach
Upcoming Events:
 Green Tradeshow – Late April
 Rossport Kayaking Symposium – Mid June
 Terrace Bay Fish Derby – Mid June to July 1
 Schreiber Heritage Days – Mid July
 Canada Day Festivities – July 1
 Terrace Bay Dragfest – August Long Weekend
 Terrace Bay Fall Crafts Fair – Early September
 Old Fashion Skating Party – Early December
Aguasabon Falls and Gorge
Rainbow Falls Provincial Park
Camping at a Local Lake
Rossport Kayaking Symposium
For More Information on Terrace Bay or Schreiber, Please Visit:
www.terracebayschreiber.ca
Or the following other websites:
North Shore Family Health Team – www.northshorefamilyhealthteam.ca
McCausland Hospital - www.mccauslandhospital.com
Village of Rossport – www.rossport.ca
Health Force Ontario - www.hfojobs.ca
Thunder Bay Regional Hospital - www.tbrhsc.com
Northern Ontario School of Medicine - www.normed.ca
Fishing on Lake Superior
Annual Dragfest in Terrace Bay
Picturesque Rossport Marina