CERTIFICATION EXAMINATION IN FAMILY MEDICINE SPRING 2012

CERTIFICATION EXAMINATION IN FAMILY MEDICINESPRING 2012FirstLastName: CFPC Member #:Due to the confidentiality of the exam please indicate in the space below a safe and secure address where we can forward the examinationmaterial.STREET ADDRESS:CITY: PROVINCE: COUNTRY:POSTAL CODE:CELL PHONE:( )OFFICE TELEPHONE:( )HOME TELEPHONE:( )OFFICE/HOME FAX:( )EMAIL:Please provide us with details if you have any dietary restrictions or food allergies.To help us assign you to the appropriate role please provide the following information. Every attempt will be made to accommodateyour choice; however this might not always be possible. I would like to participate as a: Written Exam CoordinatorThursday and Friday May 3 and 4 SAMP Marker (in Ottawa Only)TBA (Mid May) SOO Coordinator (previous Asst. Coord. participation required)Friday, Saturday, Sunday May 4-6 Assistant SOO Coordinator (previous exam participation required)Friday, Saturday, Sunday May 4-6 SOO ExaminerFriday, Saturday, Sunday May 4-6 SOO Video Taping as Simulated Candidate – Dates vary in Toronto OnlyPrev. Experience: no. of times____________________________________Language Preference: English French BilingualAge: __________Gender: Male FemaleHave you ever participated in the CFPC exam? No Yes How many times? __________Have you ever participated in practice Simulated Office Orals? No Yes How many times? __________Are you currently involved in a Residency Training Program? No Yes If yes, please state University ________________________________ Teaching Unit_____________________________________How many R2s are you responsible for training/evaluating: _________________________________________________________Please fax this form before January 6 th , 2012Attention: Melanie Almeida Fax# 1-905-629-0893

CONFIDENTIALITY AGREEMENTThe certification exams in Family Medicine and Emergency Medicine are high-stakes examinations for candidates who increasingly requirecertification to practice medicine in their chosen fields. Because examination material may be used in subsequent years, the examinationsare potentially vulnerable to compromise if material is not tightly controlled and access to it strictly limited. Inadvertent release of thismaterial through carelessness or intentional release, through copying and distributing material or divulging questions could conceivablyresult in future physicians obtaining certification who would otherwise not meet the standards of the College of Family Physicians ofCanada.Many practicing physicians give generously of their time and professional skill to aid in the examination process through exam committeework or by becoming examiners for the College. A number of these physicians also work in a residency-training capacity with residents whowill ultimately end up taking one of these exams. Some of these physicians also participate as instructors in CCFP or CCFP (EM) examtraining courses for residents or practice-eligible physicians planning to sit one of the exams. Because examiners or exam committeemembers are familiar with the content of the upcoming examinations, teaching these courses potentially puts them in a conflict-of-interestposition. In particular, concern has been expressed to the College that candidates who take these courses from examiners or examcommittee members may potentially have an “inside track” to certification.In order to protect the integrity of the Certification examination process, we ask all CFPC examination staff and all physicians whoparticipate in the production and/or delivery of the examination to sign the following attestation:I hereby attest that I will not discuss, give or divulge to anyone the content material of any CFPC examination to which I have access. Iacknowledge that all examination material is protected by copyright and I agree not to copy it for any purpose whatsoever. I agree to return anymaterials given to me upon completion of the examination process. I also understand that this attestation applies to all past, present and futureexamination material unless its release is specifically authorized by the CFPC.Name:Signature:Date: