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. This form must be completed by a program administrator (PA) / program director (PD) replacing a current program administrator/director, or for anyone filling a new position and wishing to receive PGME correspondences and/or access to systems (i.e. PGME Forms Management System, One45, and Visa or Fellowship Application System). Please select status * Residency Program Administrator Fellowship Program Administrator Residency Program Director Fellowship Program Director Education Coordinator Assistant Program Director Other Type of office staff Personal Information Title Surname * Given Name * Initial or Second Name Do you have your Fellow of the Royal College of Physicians of Canada (FRCSC) certification? Yes No Gender: Male Female Language of Correspondence EnglishFrench Are you a Canadian Citizen? * Yes No If you are not a Canadian Citizen, please provide a copy of your work permit or permanent residency certificate. Files must be less than 5 MB.Allowed file types: pdf doc docx. Download template approval letter Division Head/Department Chair Written Approval * (For Directors only)Files must be less than 2 MB.Allowed file types: pdf doc docx. Office Address (Building, Room #) * City/Prov * Postal Code * Home Address * City * Province * Postal Code * Email Address * Program Name * Business telephone number * Department * Contract Start Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Date of Birth (yy/mm/dd) (required for MedPortal access) * Contract End Date (if applicable) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 University of Ottawa Employee Number or Student Number (if available) Requested Access(Please check all that apply) One45 * Yes No XTender * Yes No uoCampus * Yes No Docushare * Yes No Elentra Access * Yes No MTD Portal * Yes No Additional Information New position or *Replacement for * Effective Date * *Upon processing of this request, the new PA/PD will be granted system accesses, while former PA/PD’s accesses will be terminated, unless otherwise specified. Comments Electronic Signature of Requestor * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
