UC Davis Health System
2111 Registration Approval Form
Applicant’s Name: ____________________________
Department Name: ____________________________
Requested By: __________________________
Requestor’s Phone #: _____________________
The process to request a 2111 Registration with the California Medical Board for a non-US trained physician is
as follows:
 Contact Kathe McDonald at 4-4955 and request placement on the next GMEC agenda and help with the
process for the J-1 visa application.
 Contact Kathrine Brisley at 4-5440 and request placement on the first MSEC meeting follow GMEC.
 Contact Antionette Caruso at 4-4617 to discuss the 2111 registration application and preparation.
Applicants must have a Social Security Number in order for the 2111 registration to be approved.
However, the application can be submitted without the SSN and when issued, a copy sent to the Board.
NOTE: It can take up to 3-6 months for the Registration to be approved by the Board.
1.
Discuss educational plan with Chief Medical Officer and obtain approval by signature.
_______________________________
Signature of CMO
2.
Present to Graduate Medical Education Committee (GMEC) a detailed postgraduate training plan
outlining the curriculum, training objectives and performance competencies. A statement regarding
the supervision requirements of this trainee must be included. All faculty involved in the
supervision of this trainee must sign the curriculum plan.
________________________________
Signature of DIO
3.
____________________
Date Approved
Present the Educational Plan to the Medical Staff Executive Committee and obtain approval from the
members.
________________________________
Signature of Chair, MSEC
4.
____________________
Date Approved
_____________________
Date Approved
Complete the UCDHS Good Standing Criteria Acknowledgement Form.
When the above requirements have been met, send copies of this approval notice, signed curriculum plan and
signed UCDMC Good Standing Criteria Acknowledgement Form to Antionette Caruso, Office of Academic
Personnel, 2300 Sherman Way, Suite 3900, Sacramento, CA 95817.
NOTE: The 2111 Registration Application will not be submitted to the Medical Board without the above
referenced documents being completed.
●●Failure to complete the process in a timely manner could result in non-appointment.●●
Revised 1/22/2014
UCDHS Good Standing Criteria Acknowledgement Form
Medical Board of California
Special Licensing Programs – Section 2111
________________ Fellowship Program – Department of ________________
Appointments under Section 2111 of the California Business & Professions Code are for physicians not eligible
for medical licensure in California who wish to pursue postgraduate study at an accredited medical school in
California. Because time spent under Section 2111 certification does not count toward requirements for board
certification or licensure, such appointments are not appropriate for ACGME accredited training. Section 2111
certification, which provides a licensing exemption and not a medical license, allows the individual to
participate in the evaluation and treatment of patients only under certain very restrictive conditions. The
Medical Board expects this clinical work to be an incidental part of an academic training experience, which
includes a significant research component.
In order to insure compliance with Medical Board regulations under Section 2111, UCDHS requires each 2111
appointee, as well as all supervising faculty and department chairs, to be familiar with and informed about these
requirements and to provide a signed acknowledgement. Any individual – and department - found to be out of
compliance with these “good standing” criteria will be subject to corrective actions that may include exclusion
from participating in the Section 2111 program. Serious violations may also lead to exclusion from
participating in the Section 2113 and 2168 programs.
Section 2111 Good Standing Criteria
1. Section 2111 candidates are appointed as Visiting Fellow through the SOM Dean’s Office of Academic
Personnel. Section 2111 appointments will only be allowed for fellowship programs that have been
reviewed and approved by the GME Office and GMEC Committee as a non-standard, non-accredited
fellowship program.
a. If applicable, the proposal for the Visiting Fellow appointment will form the basis for the visa
application through the GME Office (ECFMG J-1 “Alien Physician” Clinical Training Program).
Fellows who are expected to have significant direct patient contact (through clinical or clinical research
activities) must apply for the GME/ECFMG J-1 Visa. Given the time needed to process visa and
Section 2111 applications (typically 4-6 months), appointment request materials should be submitted
well in advance of the expected start date.
b. The application for the Visiting Fellow appointment should specify the individual’s anticipated duties
and responsibilities.
c. Section 2111 candidates may not participate in any clinical/patient care or engage in clinical research
involving direct patient contact before their Visiting Fellow appointment has been approved by the SOM
Dean’s Office of Academic Personnel and written approval of their 2111 application has been received
from the Medical Board.
2. Once approved by the Medical Board, Section 2111 appointees may participate in the evaluation and
treatment of patients only under the following conditions:
a. Clinical work may be conducted only at UCDHS.
b. Appointees must adhere to the scope of responsibilities as specified by the department chair in the
Section 2111 application to the Medical Board.
c. Appointees must be under direct supervision by a salaried UCDHS faculty member who has an active
California medical license or certification under Section 2168 (not 2113). Each appointee will have a
sponsoring supervisor and may have additional designated supervisors. Only faculty members
specifically named in the Section 2111 application are approved to supervise the trainee. The level of
Revised 1/22/2014
d.
e.
f.
g.
h.
i.
j.
supervision depends upon the clinical setting and level of potential risk (e.g., attending present at all
times during operative/invasive procedures, review with attending after patient visit in outpatient clinic
or hospital).
All nametags and badges should identify the Section 2111 appointee as a “Visiting Fellow.” The name
tag/badge must be worn at all times during patient contact.
Appointees may not bill for services.
An approved licensed physician supervisor must countersign all medical record notes, orders and
prescriptions. 2111 fellows will not be allowed access to independently sign orders, notes, or
prescriptions in the Medical Center’s computerized order entry and medical record system (i.e., access
will be similar to senior medical students).
Appointees may not represent self, or be represented, as possessing a medical license in California.
Appointees may not take night call without physical, on-site presence of an approved supervisor.
Appointees may teach students, residents or other trainees in the clinical setting but may not direct
action without input and decision by an approved attending/supervisor.
Appointees may not obtain medical staff privileges.
3. Section 2111 appointments may be renewed annually up to a maximum of three years and time spent may
not be counted as credit for licensing, board examination eligibility or approved (e.g., ACGME) residency
training. Any changes to the training program, including changes in approved supervisors, training
locations, scope of duties or areas of responsibility must be noted in the renewal application. The
sponsoring supervisor will be expected to include a summary of the fellow’s research and clinical activities,
progress, accomplishments and performance with the request for renewal.
4. All fellows, supervising faculty, and department chairs who participate in the Section 2111 program must
agree and adhere to these Good Standing Criteria, including UCDHS policies and/or Medical Board
requirements. Any individual found to be out of compliance with these Good Standing Criteria would be
subject to corrective actions, which may cause disruption to continuation of current and future 2111
program candidates. Only individuals in “good standing” will be approved for any Section 2111 application
or reapplication to the Medical Board of California.
I have read, understand, acknowledge and agree to adhere to the Section 2111 Good Standing Criteria as
specified above.
2111 Visiting Fellow:
_____________________
Signature
__________________________
Printed Name
_________
Date
Program Director:
_____________________
Signature
__________________________
Printed Name
_________
Date
Department Chair:
_____________________
Signature
__________________________
Printed Name
_________
Date
Sponsoring Supervisor:
_____________________
Signature
__________________________
Printed Name
_________
Date
Additional Supervisor:
_____________________
Signature
__________________________
Printed Name
_________
Date
Supervising Faculty
Revised 1/22/2014