Application for Midwife Staff Step Two | Quinte Health Care
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Midwife Staff Application
This streamlined application form is designed to make it easier for you to apply for an midwife position with Quinte Health Care. Once you have completed this step, you will move on to requesting professional priviledges with one or more of our hospitals. If you are seeking another position, you will not be able to use this shorter form.


Application for Appointment to the Professional Staff
Midwifery Staff
 

Full Name:


 


 




I     LICENCE and O.H.I.P. BILLING:

 
 
 


II     EDUCATIONAL QUALIFICATIONS:

Midwifery:



Postgraduate Qualifications: (list all Diplomas, certificates, degrees, memberships, fellowships)


I hold the following certifications:
           
           
           


III     CONTINUING EDUCATION

Have you participated regularly in recognized programs for continuing medical education or self-evaluation?
     


IV     PROFESSIONAL PRACTICE:

Professional Practice (prior to this application):    


V     HOSPITAL STAFF MEMBERSHIPS (Past and Present)


VI     HOSPITAL PRIVILEGES:

a) Have you ever been denied the hospital privileges for which you have applied?
   

b) Have your hospital privileges ever been reduced, suspended or revoked for any reason?
   

c) Have you ever voluntarily relinquished part or all of your hospital privileges?
   


VII     LEGAL ACTIONS

a) Please answer only the appropriate questions below.
Have you ever been the subject of an adverse finding by the Discipline Committee of the College of Midwives of Ontario?
Discipline Committee other than Ontario?
b) Has a finding of negligence or battery ever been made against you in a civil action in which you were the defendant?


IX     INSURANCE COVERAGE:

Are you a member of the Healthcare Insurance Reciprocal of Canada?
           
If you hold alternative insurance coverage, please indicate so here.
           


X     REFERENCES:

a) Professional (please provide 3 names and complete addresses of references)
 


 
 


 
 


b) Hospitals (names and complete addresses where last appointments held)
Chief of Medical Staff (last appointment)
 



 
Chief of Department (last appointment)
 



XI    

The “Declaration” (Part XIII), “Authorization for the Release of Information and Release from Liability” (Part XV) and list of procedural privileges requested (Part XIII), submitted by me with this application, constitute an integral part of this Application for Appointment to the Medical Staff.
I agree to provide a signed consent in favour of the Quinte Healthcare Corporation authorizing the said Royal College of Dental Surgeons of Ontario to provide a report regarding the proceedings taken by its Discipline Committee against me and further, advising whether or not my privileges have been curtailed or canceled by any medical licensing authority or by another hospital because of incompetence, negligence or any act of professional misconduct.
I hereby apply to the Board of Directors to be granted the privilege of performing the above procedures at Quinte Health Care’s hospital sites where resources are available to support provision of the procedure in an appropriate manner.
I solemnly declare and warrant that my past training and experience has been of such a nature and duration that I now consider myself competent and capable of proficiently performing the procedures listed above and will provide documented evidence of such competence and capability if requested by the Department Chief and/or Medical Advisory Committee.


XIII     DECLARATION:

I declare that I am the person named in this application; the statements herein contained are true in substance and in fact. I hereby apply for membership in the Department of Dentistry at Quinte Healthcare Corporation with Trenton Memorial as my primary site of practice:
In the following category:
I hereby state that I have read, and if appointed to the Professional Staff at the Quinte Healthcare Corporation, will govern myself in accordance with the requirements set out in the Bylaws, both Administrative and Medical Staff Sections, and Rules and Regulations of the Corporation and provisions of the Public Hospitals Act regarding privileges and Hospital Management Regulations.


XIV     Authorization for Release of Information and Release from Liability

To Whom It May Concern:
I, the undersigned, have made application for medical staff privileges to the Quinte Healthcare Corporation. I authorize the corporation to obtain references from medical practitioners, hospitals, individuals or medical associations whom I have referred to in my application for medical staff privileges, as may be necessary in order to consider my application for appointment.
I hereby release from liability, all representatives of the Quinte Healthcare Corporation and its Medical Staff for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications.
I hereby release from any liability any and all individuals and organizations who provide information to the Quinte Healthcare Corporation, or its Medical Staff, in good faith and without malice concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges, and I hereby consent to the release of such information.
A photocopy of this release may be provided to the persons and hospitals named as references and shall have the same authority as the original hereof.