PLDP application form This application cannot be saved. Consider typing your responses in Word or Notepad, then cut and paste your answers into the application. View sample application form Webform The completion of this application form indicates your interest and commitment to the Physician Leadership Development program for 2021-22 (Cohort #4). This program requires a considerable time commitment from participants. In addition to the six face-to-face learning modules, participants are required to participate in the following: 1.5 hour virtual kick-off prior to Module 1 A 360-degree feedback assessment prior to Module 1 Five, one-hour individual coaching sessions over the course of the program An action learning project that requires a minimum of 2-5 hours between modules Please visit the Doctors Nova Scotia website for more program details including program goals, timelines, and application process. CONTACT INFORMATION Name First Middle Last Address Address City/Town Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code Email Phone number Organization, if applicable Title, if applicable What best describes your primary work setting(s)? What best describes your primary work setting(s)? - Select -Private office/clinic (excluding free standing walk-in clinics)Community clinic/community health centreFree-standing walk-in clinicAcademic health sciences centre (AHSC)Non-AHSC teaching hospitalCommunity hospitalOther hospitalEmergency department (in community hospital or AHSC)Nursing home/ Long term care facility/seniors’ residenceUniversityResearch unitFree-standing lab/diagnostic clinicAdministrative office/corporate officeOther Please specify Specialty Number of years in practice Do you currently hold formal leadership role(s)? - None -YesNo If yes, please provide title(s) of your formal leadership role(s) and length of time in role(s). KEY QUESTIONS Where applicable, please be as specific as possible as to role, impact, and outcome 1. Tell us why you want to participate in this program and what are you hoping for as a result? Consider including a description of your strengths and areas for development. (min 250-max 500 words) 2. Tell us about yourself as a leader. (min 25-max 400 words) Consider including examples of significant change initiatives you may have led or key leadership accomplishments you are proud of and any previous leadership development training experience. 3. What is the impact you want to have in the health-care system and how will this program prepare you for that? (min 250-max 400 words) OTHER Max 100 words per question 4. Have you been encouraged or sponsored to apply for this program? If so, why? 5. Is there any other information you would like the selection committee to consider? 6. Are there any barriers to your full participation, attendance, and commitment to the program? 7. Have you previously applied to this program? If yes, what made you re-apply? 8. Health inequities are preventable disparities in the health outcomes and access to resources between populations. They are the result of systemic racism, colonialization, discrimination and oppression and result in inequity in social and economic conditions. Doctors Nova Scotia recognizes the role of health inequities in the health of Nova Scotians and prioritizes applicants who self-identify as LGBTQ2SIA+ or as a Person of African descent, Indigenous (First Nations, Inuit, Metis), or Person of Colour. Do you self-identify as belonging to a historically underrepresented and/or marginalized group, such as Indigenous peoples, African Nova Scotians, people of colour, newcomers to Canada, LGBTQSIA+ people, or people with disabilities? If you are comfortable sharing the aspects of your identity that are relevant to physician leadership, we invite you to do so: OPTIONAL Link to LinkedIn Profile Attach resume Upload Upload requirementsOne file only.512 MB limit.Allowed types: pdf, doc, docx, zip. All applications will remain confidential and be reviewed by a selection committee. Submit Next steps
