Field Rotation & Vacation Confirmation Form
Please use this form to submit your confirmed rotation schedule. This form will be relied upon to complete your POWER profiles. Please submit a new form for each rotation. These forms will be saved to your Resident profiles and will be used for auditing purposes, so it's important that you submit a form for each rotation.

This form may also be used to submit vacations.

Thanks,
PHPM Program Coordinator

First Name
Legal name please
Your answer
Last Name
Legal name please
Your answer
Rotational PGY Year
Select an option. Please select the PGY Year associated with the rotation.
Rotation Service Description /Vacation
This is your rotation type.
If you selected "Elective" please provide details on the type of elective
i.e. content area
Your answer
Start Date
MM
/
DD
/
YYYY
End Date
MM
/
DD
/
YYYY
Supervisor
Supervisor (OTHER)
If you selected OTHER above please provide the following information: First & Last Name, Institution, Title(s), and Faculty Affiliation, CPSO number(if applicable), and an email address for contact (ex. Barry Pakes, Public Health & Preventive Medicine Program Director, Dalla Lana School of Public Health, 76565, barry.pakes@utoronto.ca) *Avoid using abbreviations * For vacations put N/A
Your answer
Location
If you select other please specify. Avoid using abbreviations.
Location(s) (OTHER)
If you selected "OTHER" above, please include the following details: Name of the organization, the specific unit that you'll be working with, and the mailing address of that specific unit
Your answer
Notes
Any notes you wish to add
Your answer
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