Consent To The Disclosure Of Personal Information To Provincial and Territorial Governments For Recruitment Purposes

Reason for Consent

Under the Canadian Constitution, provincial and territorial governments have the primary responsibility for the delivery of health services, including training, licensure and management of physicians. Provincial and territorial governments wish to recruit physicians, who are pursuing postgraduate medical training in the United States, to return to particular areas or facilities in Canada at the completion of their training. For this reason, applicants are requested to consent to the disclosure of personal contact information by the federal government to provincial and territorial governments for recruitment purposes. Note that disclosure of contact information will not automatically result in employment offers. Declining to sign this consent to the disclosure of personal information will not affect Health Canada's decision whether or not to issue a Statement of Need.

Type of Personal Information to which the Consent Refers

• Physician's name, mail and e-mail address(es), and contact number(s) in the United States
• Area of medical specialty training
• Expected or anticipated date of completion of postgraduate medical training in the U.S.
• Name(s), mailing address(es), e-mail address(es) and contact telephone number(s) of the physician's program director(s), hospital(s) and university(ies) in the United States.
• The physician's CV.
• Province or territory which provided a letter of endorsement or support (only if applicable).

Intended Purpose of Disclosure of Personal Information

Provincial and territorial governments and regional health authorities will use the information for recruitment purposes.

Organizations to which Disclosure will be made

Provincial and territorial Ministries of Health or equivalent, and/or regional health authorities.

Safeguards to Protect Individual Privacy

Health Canada will periodically send to provincial and territorial governments a printed or electronic report on the numbers of physicians who are training in the U.S. with a J-1 Visa, the areas of medical specialty, and the expected or anticipated dates of completion of training. Specific personal information will not be included in these reports. Health Canada will release the personal information to which this consent refers, as described above, only after a request is made by a province or territory.

Applicant's Initials:

The personal information will be released to a provincial or territorial government physician resource planning officer, to a provincial or territorial government physician recruitment officer, or to a recruitment officer from a regional health authority.

Health Canada has an agreement with the provincial or territorial government representative or the regional health authority representative stipulating that he or she will not disclose personal information to any other persons or organizations without first obtaining the physician's consent.

General

The Consent Form may be signed at the time of application for a Statement of Need or at any time during the training in the United States.  The applicant may also at any time request that Health Canada send his/her personal information and curriculum vitae to a provincial or territorial government representative, a physician recruiter, or a regional health authority.

Physicians have the right to examine their record held at Health Canada and to request correction, if required.

I consent to the disclosure of personal information to provincial and territorial governments and/or regional health authorities for recruitment purposes.

Signatures of Applicant and Witness

Print Name of Applicant:
Signature of Applicant:
Date

This Consent is Signed in the Presence of:

Print Name of Witness:
Signature of Witness:
Date:

Declining to sign this consent to the disclosure of personal information will not affect Health Canada's decision whether or not to issue a Statement of Need.

Please remember to submit both pages of this form.