FELLOWSHIP

FCFP(S) Summative Exit Examination

FAMILY MEDICINE FELLOWSHIP PROGRAMME
Declaration for Year 2021

Information Required

The declaration submission process will take about 5 to 10 minutes.

You will require the following documents to complete your submission:

Vaccination Report (if any)
Letter of Approval from your CEO/CMB/Medical Director or equivalent
Supporting documentation for why you are not fully vaccinated (if required)

(A) PERSONAL PARTICULARS

MCR Number *

Example: M12345E

Full Name (as per NRIC) *

(B) EMPLOYER DETAILS

Healthcare Institution (HCI) / Clinic / Workplace *

Example: Toa Payoh Polyclinic, Outram Community Hospital, or XYZ Family Clinic & Surgery

Are there any segregation policies from your workplace? *

Example: split teams, zonal restrictions and/or work shifts requirements

Please upload a copy of your Approval Letter *

Click or drag a file to this area to upload.

Approval Letter should be signed off by your CEO / CMB / Medical Director or equivalent

(C) VACCINATION STATUS

Are you fully vaccinated for COVID-19? *

“Fully vaccinated” means two weeks after receiving a full regimen of the Pfizer-BioNTech/Comirnaty or Moderna vaccines, or any of the vaccines on the WHO EUL listing, with the vaccination status updated in MOH’s national IT system.

Are you on your HCI / workplace's Rostered Routine Testing (RRT)? *

Please provide more details *

If Yes, please let us know the frequency and if the RRT is Antigen Rapid Test (ART) or Polymerase Chain Reaction (PCR)
If No, please let us know the reason for you not being on RRT

Signature *