Print Form
Submit To: Graduate Medical Education
Education Bldg., Ste. 4202
Page 1 of 3
VISITING RESIDENT AUTHORIZATION FOR SHORT-TERM ROTATION TO
UCDHS WHERE NO AFFILIATION AGREEMENT EXISTS
TYPE ONLY
Name:
(Last)
(First)
(Middle)
Post Graduate Training Level:
Social Security No.:
PI #:
Training Specialty:
Home Institution:
DOB:
Medical Service to Which Assigned at UCDHS:
NPI #:
Rotation Start Date:
Med Lic. No.:
Exp. Date:
Rotation End Date:
Exp. Date:
TB Skin Test Current (through period of rotation):
Rubella Titer or Immunization Date:
HIPPA Training Date:
Yes
DEA No.:
Exp. Date:
Signed Confidentiality Agreement:
No (agreement kept by Department)
Signed Needlestick Form:
(agreement kept by Department)
Medical School:
Graduation Date:
ECFMG Certificate Number:
Date Valid Indefinitely:
Insurance Certificate
Proof of insurance (check one):
•
•
•
•
•
•
•
•
or
Other (specify)
UCDHS has reviewed the credentials of the Resident and has accepted the Resident for an elective rotation. The privileges to be granted to the Resident are listed in the
Description of Duties, which will be provided to the resident by the UCDHS Department sponsoring the rotation.
Home Institution and the Resident shall assure all documentation requested in Attachment 1 is provided as directed and shall comply with all requirements listed therein, as
applicable.
Home Institution warrants no disciplinary actions have been taken or are pending against the Resident and the Resident has not been involved in any claims, actions or formal
complaints related to patient care.
The Resident shall perform the duties and responsibilities listed in the Description of Duties. During the rotation, the Resident shall comply with UCDHS policies and procedures.
Home institution or the Resident shall provide professional liability coverage applicable during the rotation and shall provide evidence of coverage to UCDHS before the rotation
begins.
UCDHS and Home Institution each agree to defend, indemnify and hold each other and each other's respective officers, agents, and employees, harmless from and against any
and all claims liability, loss, expense, including reasonable attorneys' fees, or claims for injury or damages arising out of the performance of the rotation, but only in proportion to
and to the extent such liability, loss, expense, attorneys' fees, or claims for injury or damages are caused by or result from the negligent or intentional acts or omissions of the
indemnifying party, its officers, agents, or employees.
During the rotation, the Resident shall be considered neither a student nor employee of UCDHS.
Upon completion of this rotation, the Resident shall return UCDMC photo-ID badge, University keys, and any other University property loaned to the resident during the rotation.
APPROVED AND AGREED
Signature
(1st) Visiting Resident
__________________________________________
Print Name
Email Address:
Date:
Signature
(2nd) Training Program Director - Home Institution
Date:
Signature
Pamela Dimand
(4th) Manager, Graduate Medical Education, UCDHS
Date:
Signature
(5th) Annie Wong, Manager, Health System Contracts Office
Date:
Form completed by:
Signature
(3rd) Training Program Director - UCDHS
Revised: 04/15/2008
Date:
Telephone No.:
Page 2 of 3
SHORT TERM
AFFILIATION/ROTATION AGREEMENT
REQUEST FORM
Department(s) Requesting Rotation:
Department(s) Contact(s) Person(s)
Name:
Phone:
E-mail:
Name of Resident/Fellow Rotating:
Please Check One:
Type of Clinical Service/Rotation:
Date(s) of Rotation:
If rotating externally:
Is this experience available at UCDHS?
No
Yes
Does this rotation support one or more of the University's Teaching/Education, Community/Public Service,
No
Yes
Patient Care or Research Missions?
Name of Other Institution:
Other Institution Contact(s) Person(s)
Name:
Address:
E-mail:
Name of Preceptor/Supervisor:
Will either party pay the other in this arrangement?
Yes
If applicable, Please describe any non-standard joint responsibilities:
Approving Signatures:
Department Residency Program Director
Date:
UCDHS Manager/Assistant Dean, GME
Date:
No
Submit To: Graduate Medical Education
Education Bldg., Ste. 4202
Page 3 of 3
ATTACHMENT 1
AUTHORIZATION FOR ROTATION CHECK SHEET
A.
DOCUMENTS TO BE SUBMITTED TO GRADUATE MEDICAL EDUCATION OFFICE
Authorization for Rotation Forms must be submitted by home department to the Graduate Medical Education
Office at least10 days prior to the start of the rotation.
* Authorization for Rotation Form, signed and dated by UCDHS Training Program Director, Rotating Resident and
Training Program Director from home institution.
* Copy of insurance certificate and/or letter of indemnity.
* Copy of TB, Rubella, Rubeola, Varicella and Hepatitis clearance (current). Absence of health clearance
documentation will necessitate the Rotator's go thru by Employee Health Services to obtain clearance before the
rotator may begin service. TB test is current within a year from the date recorded on the Vaccination
Administration Record.
* Copy of Medical Diploma (must include medical school attended and graduation date).
* Copy of ECFMG certification and the date valid indefinitely.
B.
DOCUMENTS TO BE RETAINED BY DEPARTMENT
* Listing of Duties, Responsibilities and Privileges.
* Medical License number and expiration date (include data in auth form).
* DEA Certificate number and expiration date (include data in auth form).
* CPR Certificate.
* Signed Needle-Stick/Blood-Body Fluid Exposure Policy.
* Signed Confidentiality Agreement.