New Program Administrator / New Program Director Registration Form

Disclaimer: This information will be shared with the Faculty Affairs and Medtech offices in order to grant you IT access.

Program Administrators are asked to complete this form to ensure that PGME has the required information regarding the appointment of the new Program Director, Assistant Program Director, Program Administrator, etc.

Please refer to the procedure outlined in the PGME Policy and Procedures on Appointing a Program Director and the Program Director Job Description.

Submitter information

Name

Role

Email

Department Name

Program Name

Contract Start Date

Contract End Date

(if applicable)

Please select role

Residency Program Administrator 

Fellowship Program Administrator

Residency Program Director 

Clinical Fellowship Director 

AFC Fellowship Director

Education Coordinator

Assistant Program Director

Other

New Director

Name of proposed program director

Title

Given Name

Initial or Second Name

Surname

Date of Birth

University of Ottawa Email Address 

Preferred Email Address 

Office Address

Building

Room number

City/Town

Province

Postal Code 

The new Program Director has a mentor/coach to orient them in the new role:

Yes

Please specify the mentor/coach

PGME will assign the new Program Director a mentor. The Vice Dean will discuss with the new Program Director at their orientation meeting.  

Outgoing Program Director  

Full Name

Contract End Date

Date of Removal of Permissions for One45 and Elentra

New Residency Program Administrator, Fellowship Program Administrator or Education coordinator

Name of new residency program administrator, fellowship program administrator or education coordinator

Title

Given Name

Initial or Second Name

Surname

Date of Birth

University of Ottawa Email Address 

Preferred Email Address 

Office Address

Building

Room number

City/Town

Province

Postal Code 

Outgoing Residency Program Administrator, Fellowship Program Administrator or Education coordinator

Full Name

Contract End Date

Date of Removal of Permissions for One45 and Elentra

New Other Roles

Name of the role

Name of new person assuming the role

Title

Given Name

Initial or Second Name

Surname

Date of Birth

University of Ottawa Email Address 

Preferred Email Address 

Office Address

Building

Room number

City/Town

Province

Postal Code 

Outgoing person in the role

Full Name

Contract End Date

Date of Removal of Permissions for One45 and Elentra

Comments

Electronic Signature of Requestor 

Sign below