Please hand this paper to your spouse or significant other... now.
The Vanderbilt Housestaff Alliance is a nonprofit social and service organization
of the spouses and significant others of the Vanderbilt housestaff and alumni.
What does that mean? Spouses and significant others… we are here for you! We are a group of people who have
something in common: a resident or fellow! When you join the VHA, you will have opportunities to explore
Nashville and get connected with others in the Vanderbilt community. We look forward to meeting you along the
way!
Our active members take part in…
 Monthly Events: Welcome Picnic, Full Moon Pickin’ Party, Cooking Class at Whole Foods, Brunch with
Santa, Grand Ole Opry, Pottery Painting, Steeplechase, and more!

Various Groups: Children’s Playgroup, Book Club, Girls Night Out, Women’s Bible Study, Fitness Club,
Cooking/Food Club and more!

“Matters of the Heart” you and your spouse or significant other can enjoy a night out with Matters of the
Heart - dinner, drinks, and childcare are provided.

VHA Mentors who can help you answer questions and help you adjust to life in Nashville! Email us
(president@vhalliance.org) and we’ll connect you with a mentor! VHA Mentors are a great resource –
they’ve been there and are here to help.

The VHA Newcomers Guide An email will be sent to your resident or fellow. Check it out! The Newcomers
guide can help you in your transition to Nashville - from areas of town, to restaurants, to childcare and
much more! Need a local for real estate, banking, etc.? The VHA Newcomer Guide has it all!
Join us today!
vhalliance.org
Membership dues are $40 per year for an entire housestaff family. Member privileges include, but are not restricted to,
participation in social functions, service events, interest group activities, subscription to the HouseCalls monthly newsletter, and a
membership directory. How to Join: Visit vhalliance.org. Click “Join VHA or Renew”. Complete the PayPal Payment of $40.
Complete the Registration Form (link will be provided upon payment).
VANDERBILT UNIVERSITY � MEDICAL CENTER
Donald W. Brady, M.D.
Senior Associate Dean for CME and
Continuing Professional Development
ACGMEINRMP Designated Institutional Official
Office of Graduate Medical Education
Date, 2016
Name, M.D. |
Address
Dear Dr. Name:
e
It is my pleasure to confirm your appointment to Vanderbilt University Medical Center as a Title in
the Program Training Program for the period of Date, 2016 through Date, 2017. You will be appointed
at PGY Level ? and your stipend will be $? annually. You will be paid on the last working day of each
month.
Before we can complete processing for payroll, we will need to have the following items
completed and returned immediately (within two weeks of the date of this letter) :
m
pl
• Signed House Staff Agreement
• Signed VUMC Confidentiality Agreement
• CV current up to this appointment
• Consent for pre-employment background check (on-line, see enclosed instructions)
Additionally, we need to have the following documents prior to your start date:
• An official 'final transcript' from your professional school indicating
proof of the awarding of your professional degree. This transcript needs to
be sent directly from your professional school to the GME office.
• Copy of any certificate(s) for previous residency/fellowship training.
Our address is:
Vanderbilt University Medical Center
Office of Graduate Medical Education
201 Light Hall
Nashville, TN 37232-5283
If you have any questions, contact the staff of the Graduate Medical Education Office by phone at 615322-4916, or by e-mail at gme.office@vanderbilt.edu.
Sa
Department Chairperson, Professor and Chair of Department, and the entire staff of Graduate Medical
Education join me in looking forward to a beneficial and enjoyable association with you.
Sincerely,
D��D
Senior Associate Dean for Graduate Medical Education
ACGMEINRMP Designated Institutional Official
DWB/ww
Enclosures:
• VUMC Confidentiality Agreement Form
• House Staff Agreement
• Instructions for Consent to Background Check
cc: Sandy Bledsoe
201 Light Hall
Nashville, TN 37232-5283
tel 615.322.6035
fax 615.343.1496
www.mc.vanderbilt.edu/gme
VANDERBILT UNIVERSITY MEDICAL CENTER
HOUSE STAFF AGREEMENT 2016-2017
Sa
m
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e
In accepting this appointment, I hereby agree to:
1) Satisfy the conditions of employment as contained in the House Staff Manual
(http://www.mc.vanderbilt.edu/documents/gme/files/HSManual.pdf).
2) Abide by the applicable Medical Staff Bylaws, Rules and Regulations, House Staff Manual, and Vanderbilt University and
Vanderbilt University Medical Center (VUMC) policies and procedures, including but not restricted to policies on Privacy, HIV
exposure and the Alcohol and Drug Use Policy.
3) Abide by the VUMC Graduate Medical Education Committee policy on duty hours.
4) Honestly and accurately report all duty hours, including any hours spent in internal or external moonlighting.
5) Demonstrate an understanding and acceptance of my personal role in a) the safety and welfare of patients entrusted to my
care; b) the provision of patient- and family-centered care; c) responsibility for my personal fitness for duty; d) management of
my time before, during, and after clinical assignments; e) recognition of possible impairment, including illness and fatigue, in
myself and my peers, and seeking assistance from the appropriate resources; f) monitoring of my patient care performance
improvement indicators; and g) honest and accurate reporting of patient outcomes and clinical experience data.
6) Attend to lifelong learning through continuing my personal program of self-study and professional growth, with guidance from
the faculty and teaching staff.
7) Participate in quality patient care, commensurate with the responsibility delegated to me by virtue of my level in the clinical
training program.
8) Participate fully in the educational activities of my clinical training program.
9) Participate in official VUMC programs and activities involving the medical staff, including institutional committees and councils,
to the extent requested.
10) Rotate, when required to do so by my program, to the designated affiliated hospitals, and to adhere to the established
procedures, policies, and regulations of these affiliated institutions.
11) To accept or participate in extracurricular employment (internal or external moonlighting) only as is consistent with the policies
of VUMC and with the specific written approval of my Chief of Service and the Senior Associate Dean for Graduate Medical
Education.
12) Render to my patients safe, efficient and the most cost-effective medical care possible.
13) I understand that I am not entitled to be paid by Vanderbilt University in the event the military, the NIH or other third party
compensates me for my post graduate clinical training. In the event I am compensated by Vanderbilt University, I agree to
repay all over-payments.
14) I understand that this constitutes an annual appointment only, and that renewal with progression to the next level, renewal
with non-promotion, or non-renewal will depend upon whether or not I have met or exceeded the requirements of my clinical
training program.
I understand that Vanderbilt University Medical Center will provide:
1) An environment in which I may continue my medical education and develop the knowledge and skills essential for medical
practice.
2) A culture of professionalism that supports patient safety and personal responsibility and whose faculty members demonstrate
an understanding and acceptance of their personal roles in a) the safety and welfare of patients entrusted to my care; b) the
provision of patient- and family-centered care; c) fitness for duty; d) management of my time before, during, and after clinical
assignments; e) recognition of possible impairment, including illness and fatigue, in myself and my peers, and appropriate
intervention; f) monitoring of my patient care performance improvement indicators; and g) honest and accurate reporting of
patient outcomes and clinical experience data.
3) The availability of schedules that inform all members of the health care team of attending physicians and residents currently
responsible for each patient’s care.
4) A review of my performance by my clinical service, by which I am informed of my progress at least semi-annually.
5) A salary commensurate with my level of responsibility as indicated on the accompanying letter which is made a part hereof.
6) Three weeks vacation per year.
7) Leave for which I may qualify (sick leave, FMLA, personal, etc.) as defined in applicable provisions of the House Staff Manual.
Please reference the House Staff Manual for how leave and other absences may affect the fulfillment of Board requirements.
8) Grievance process for non-academic issues including claims of discrimination, harassment, and/or retaliation in accordance
with the applicable provisions of the House Staff Manual and/or Vanderbilt University policy.
9) Appeals process, as described in the House Staff Manual, for Corrective Action measures or if I am terminated prior to the
termination date of this agreement.
10) Occurrence based professional liability coverage for claims occurring as a result of my official duties as a resident.
11) Health insurance, disability insurance, and life insurance.
12) Medical and psychological support services, including but not limited to an exercise facility; evaluation and treatment of work
related and non-work related illnesses and injuries; and counseling for those experiencing emotional, marital, or substance
abuse problems.
13) A physician impairment/substance abuse program as described in the House Staff Manual and Hospital Policy 30-08.
14) Uniforms and laundry of uniforms.
15) On-call in-house meals at VUMC.
16) On-call in-house sleeping quarters at VUMC and adequate sleep facilities and/or safe transportation options for residents who
may be too fatigued to safely return home.
17) Adequate notice, and assistance in relocation, should my training program be downsized, modified, or cease to exist.
18) Accommodations for residents with disabilities as required by the Americans with Disabilities Act and in accordance with
Institutional Policy.
19) I understand that the institution will make available to me the procedures contained in the Disciplinary Guidelines for Graduate
Medical Education and Vanderbilt University House Staff Manual where applicable. I accept the appointment as offered under
the terms and conditions as described herein (http://www.mc.vanderbilt.edu/documents/gme/files/HSManual.pdf).
e
Third-party Compensation/Financial Support
Are you now, or will you during the current year, be on active duty and/or receive financial support from the military, the NIH
or other third party? If yes, please provide a copy of your military, NIH or other applicable agreement.
pl
____Yes ____No
Consent To Assignment of House Staff Agreement
m
I understand and acknowledge that the clinical enterprise currently owned and operated by Vanderbilt University
(“VU”) will be transferred to a new not-for-profit, tax-exempt entity, Vanderbilt University Medical Center
(“VUMC”). This transfer is expected to become effective on or about April 30, 2016. The actual date the transfer
becomes effective is referred to below as the “Effective Date”. I understand and acknowledge that, on and after the
Effective Date, my house staff appointment and employment will be with VUMC, rather than with VU.
Sa
By signing below, I hereby consent to VU’s assignment to VUMC, as of the Effective Date, of (1) the above standard
House Staff Agreement for 2016-2017, and (2) any Confidentiality Agreement with VU that I enter into
(“Agreements”). I understand and agree that on and after the Effective Date, VUMC shall be solely responsible for
any obligations of VU and the medical center set forth in the Agreements and VUMC shall be entitled to enforce my
obligations as set forth in the Agreements. I acknowledge and agree that any references in the Agreements to rules,
policies, procedures and/or manuals of “Vanderbilt University” or the “medical center” or similar references shall be
deemed to refer to the rules, policies, procedures and/or manuals, as applicable, of VUMC on and after the Effective
Date.
_________________
_____________
Signature
Date
Confidentiality Agreement
Vanderbilt University Medical Center (VUMC) has legal and ethical responsibilities to safeguard the
privacy of its employees, students, and patients and their families and to protect the confidentiality of
protected health information (PHI) and all other types of confidential information (collectively, “Confidential
Information” as further defined below). Members of the VUMC community to which this Confidentiality
Agreement applies include but are not limited to a:
Workforce Member: an individual performing work on behalf of VUMC and under the direct
control of VUMC, whether or not the member is employed by VUMC. Examples include staff;
faculty; temporary agency workers; students; contractors; and volunteers.

Trusted Role: a Workforce Member whose job duties require access to VUMC Confidential
Information in order to provide legal or risk management advice to the institution, perform audit or
review duties or investigations or to provide support for an information system. An individual in a
Trusted Role is held to a higher standard of personal integrity, professionalism and judicious
precaution when accessing Confidential Information.

Extended Community Member: an individual who is present on VUMC premises or accessing
information resources at VUMC for a specific treatment, payment, or health care operation
business purpose allowed under the Health Insurance Portability and Accountability Act (HIPAA)
such as a third party payer representative, a visitor for a guided tour or observation experience,
media or vendor representatives, or other health care providers involved in a patient’s continuum
of care.

Business Associate: a person or entity, other than a Workforce Member, that performs certain
functions or activities on behalf of, or provides certain services to, VUMC that involve the use,
disclosure, creation, receipt, maintenance or transmission of PHI.
m
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e

VUMC’s Confidential Information includes any and all of the following categories:
Patient information (or PHI) including demographic, health, and financial information, pictures and
videos (in paper, verbal, observed or electronic form regardless of how it is obtained, stored,
utilized, or disclosed);
Sa


Information pertaining to members of the VUMC Workforce or Extended Community (such as
social security numbers, banking information, salaries, employment records, student records,
disciplinary actions, etc.);

VUMC information (such as financial and statistical records, academic or research funding,
strategic plans, internal reports, memos, contracts, peer review information, communications,
proprietary information including computer programs, source code, proprietary technology, etc.);

Third-party information (such as insurance, business contracts, vendor proprietary information or
source code, proprietary technology, etc.); and

Patient, research, academic program, or other confidential or proprietary information heard or
observed by being present on VUMC premises.
As a member of the VUMC community I agree to conduct myself in strict conformance with all applicable
laws and with VUMC policies governing Confidential Information. I understand and agree that measures
must be taken so that all Confidential Information captured, maintained, or utilized by VUMC and any of its
off-site clinics or affiliated entities is accessed only by authorized users. These obligations apply to
Confidential Information in any form, e.g., written, electronic, oral, overheard or observed.
Page 1 of 3
(MC 9967) 02/2016
As a condition of and in consideration of my use, access, maintenance and/or disclosure of Confidential
Information, I agree that:
1. I will access, use, maintain and disclose Confidential Information only as authorized and needed
to perform my assigned job duties. This means, among other things, that I:
a) will only access, use, and disclose Confidential Information that I have authorization to
access, use, and disclose in order to perform my job duties;
b) will not in any way access, use, divulge, copy, release, sell, loan, review, alter, or destroy any
Confidential Information except as properly and clearly authorized within the scope of my job
duties and in accordance with all applicable VUMC policies and procedures and with all
applicable laws;
e
c) will report to the Privacy Office or my supervisor any individual’s or entity’s activities that I
suspect may compromise the privacy or security of VUMC’s Confidential Information or
otherwise fail to conform to VUMC policies and procedures;
pl
d) understand my violation of my obligations regarding Confidential Information, particularly PHI,
could expose me to legal sanctions.
2. If I am granted access to VUMC electronic systems, including email, I am the only person
authorized to use the individual user identification names and passwords or access codes
assigned to me. I agree to the following:
m
a) I will safeguard and not disclose my individual user identification passwords, access codes or
any other authorizations that allow me to access VUMC Confidential Information to anyone
including my manager, supervisor, IT Support staff or any other person who is not authorized
to have this information.
Sa
b) I understand that if I am in a Trusted Role I will be held to a higher standard of personal
integrity, professionalism and judicious precaution when accessing Confidential Information.
c) I will not request access to or use any other person’s passwords, access codes or other
authorizations.
d) I accept responsibility for all activities undertaken using my passwords, access codes and
other authorizations.
e) It is my responsibility to log out of any system to which I have logged on. I will not under any
circumstances leave unattended a computer to which I have logged on without first either
locking it or logging off the workstation.
f)
If I have reason to believe that the confidentiality of my passwords or access codes have
been compromised, I will immediately report this to the VUMC Help Desk, Privacy Office and
my supervisor, and I will immediately change my password.
g) I understand that my user identification will be deactivated at such time when I am no longer
a VUMC Workforce Member, Extended Community Member, or Business Associate; or when
my job duties no longer require access to the computerized systems.
h) I understand that VUMC has the right to conduct and maintain an audit trail of all accesses to
Confidential Information, including, but not limited to the machine name, user, date, and data
accessed and that VUMC may conduct a review of my system activity at any time and without
notice in order to monitor appropriate use.
Page 2 of 3
(MC 9967) 02/2016
i)
I understand and accept that I have no individual rights to or ownership interests in any
Confidential Information referred to in this agreement and that therefore VUMC may at any
time revoke my passwords or access codes.
j)
I understand that if I access or maintain Confidential Information on any personal device I
must abide by all VUMC mobile device management policies.
k) I will not forward Confidential Information including but not limited to PHI, pictures or videos to
my personal email or to any social media accounts.
I understand that it is my responsibility to be aware of VUMC Information Management
policies, applicable Human Resource policies, and other policies that specifically address the
handling of Confidential Information and misconduct that may warrant immediate discharge
or other disciplinary action.
e
l)
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m) I understand that in addition to protecting Confidential Information I am also required to be
aware of the Electronic Communications and Information Technology Resources policy and
to abide by all of its requirements regarding the appropriate use of VUMC computer systems.
n) My obligation to safeguard VUMC Confidential Information, including PHI, continues after I
am no longer affiliated with VUMC.
m
My signature below indicates that I have read, accept, and agree to abide by all of the
requirements described above. I acknowledge that any violation of these requirements may result
in disciplinary measures up to and including termination of employment and/or affiliation with
VUMC.
Sa
Print Name: ________________________________________ Job Title: _________________________
Signature: _________________________________________________ Date: ____________________
Department/School or Company: _________________________________________________________
Page 3 of 3
(MC 9967) 02/2016
SUPPLEMENTAL BACKGROUND CHECK AUTHORIZATION, CONSENT AND RELEASE
I understand that Vanderbilt University (“VU”) will use a third party vendor to conduct a background check on
me for employment purposes related to my becoming a member of the house staff. As part of the required
background check, I am being provided with Disclosure form(s) concerning the process, and Authorization,
Consent and Release form(s) to be signed authorizing VU to conduct a background check.
I understand that on or about April 30, 2016 (“Effective Date”), a transaction will become effective that will
result in my appointment and employment being with Vanderbilt University Medical Center (“VUMC”), not
VU. This transaction is explained in the 2016-2017 House Staff Agreement, which is also being provided to
me.
By signing below, I hereby authorize VU to share with VUMC any background check information or results
that VU receives before or after the Effective Date, and I authorize VU and VUMC to use such information
and results to the full extent permitted by law. The Authorization, Consent and Release form(s) will remain in
full force and effect and apply to both VU and VUMC.
_____________________________
Signature
_____________________________
Printed Name
_______________________
Date
Pre-Employment Task List
The Office of Graduate Medical Education has created this task list to help you organize the many details necessary to
begin your residency or fellowship. It is very important that you comply with the instructions and complete each
task. Failure to do this according to the timeline in the sidebar may delay your start date, along with your pay and
benefits. There’s a lot to do; so, let’s get started!
VANDERBILT SYSTEMS LOGIN - VUNETID and EPASSWORD
See the “VUnetID and ePassword Creation Procedure” insert in this folder and follow the instructions.
Your VUnet ID and ePassword will be used to log in to the House Staff Portal, email and various Vanderbilt
systems. Note: It may take up to 30 minutes before you can access systems after setting up your login.

I completed this task.
SOCIAL SECURITY NUMBER UPDATE
Log in to the House Staff Portal (https://gme.mc.vanderbilt.edu/gmeportal). Enter your social security
Number, if prompted. If not prompted, we have your social security number on file. ERAS doesn’t provide
us with your social security number so we will need this information for the credentialing process and
payroll. The collecting and storing of this information through our portal is secured behind the Vanderbilt
firewall.

I completed this task.
Immediate
ELECTRONIC TASK LIST
To use the electronic version of this task list, log in to the House Staff Portal
(https://gme.mc.vanderbilt.edu/gmeportal) and click “Pre-Employment Task List”.

I completed this task or will be using this print version of the task list.
TRANSCRIPT REQUEST
›
I HAVE GRADUATED.
Request your medical school registrar send a final, official, original transcript to this address:
Vanderbilt Medical Center
Graduate Medical Education Office
c/o Audrey Patrick
2215 Garland Ave
201 Light Hall
Nashville, TN 37232-5283
Some institutions provide secure electronic delivery of official transcripts. These submissions may be made
to audrey.patrick@vanderbilt.edu.
›
I HAVE NOT YET GRADUATED.
Make sure your registrar will send a FINAL (degree-awarded) transcript as soon as it is available.
›
I AM CURRENTLY A VANDERBILT MEDICAL STUDENT.
Request a final (degree-awarded) transcript through YES: http://yes.vanderbilt.edu/.
›
I WENT TO MEDICAL SCHOOL OUTSIDE THE US.
If it is impossible to have an original transcript sent to us from that school, let us know
(GME.Office@vanderbilt.edu), then bring your original transcript AND original diploma to the GME
office as soon as possible. Mailed or emailed copies will not satisfy the requirement.

I completed this task.
BACKGROUND CHECK APPLICATION
1. An email from PEBC.VUMC@Vanderbilt.edu with a link to VPAssure will be sent to both your
personal email address on file and your new Vanderbilt email address, if available.
Page i
2. Read the directions in the email carefully and click on the link to complete all sections of the
request.
3. On the Request Details Tab enter information in the following tabs:
i.
Employment – list up to two (2) former employers starting with the most recent.
› I HAVE DONE/AM DOING A RESIDENCY/FELLOWSHIP
Residencies/fellowships are considered employment, so be sure to include your training
institution as an employer.
› I HAVE NEVER BEEN EMPLOYED BEFORE
You must still complete the online background check application even if you have not been
employed previously. Enter “NA” in all required (pink highlighted) text fields and the year
(ex: 2016) in the date fields.
ii.
International Address History
›
I HAVE NOT LIVED OUTSIDE OF THE US
›
I HAVE LIVED OUTSIDE OF THE US, AM A NON-CITIZEN OF THE US, OR WENT TO MEDICAL SCHOOL OUTSIDE
THE US.
An International background check will be processed on you. Include all previous addresses
out of the US, in which you have lived, in the International Address History section.
Education Disclosure- list all higher level education schools you have attended, including
schools outside of the US.
Type “No” in the details field.
iii.
Immediate
›
I HAVE QUESTIONS ABOUT THE BACKGROUND CHECK PROCESS.
Contact Jaimie Glatt, Vanderbilt Background Administrator, by phone (615-875-9657) or email
(PEBC.VUMC@Vanderbilt.edu)
›
I AM HAVING TECHNICAL ISSUES WITH THE VPASSURE (VERIFIED PERSON ASSURE) WEBSITE
Contact Verified Person Support at 866-380-6100.

I completed this task.
MAIL TO GME - AGREEMENTS, TRAINING CERTIFICATES, and DEA CERTIFICATE
1. Sign your House Staff Agreement (your contract), VUMC Confidentiality Agreement, and the
Supplemental Background Check Authorization, Consent and Release form in pen. These three
documents are in this folder.
2. Make copies of these three documents and keep the copies with your original Appointment Letter
(you will need some of these for employment/income verification for loan applications, housing, etc.)
3. Make a copy of any Training Certificates you have (certificates of completion of
internship/residency/fellowship).
4. In the GME Office-addressed envelope that is in this folder, mail the following items :
i.
Your original signed House Staff Agreement, VUMC Confidentiality Agreement, and
Supplemental Background Check Authorization, Consent and Release form.
ii.
Copies of your Training Certificates (if applicable and currently available)
iii.
Copy of your DEA Certificate (if you have a personal DEA # AND an active TN medical license).
›
I LOST/DON’T HAVE MY HOUSE STAFF, CONFIDENTIALITY AGREEMENTS AND SUPPLEMENTAL BACKGROUND CHECK
AUTHORIZATION, CONSENT AND RELEASE FORM. Let us know (GME.Office@vanderbilt.edu).
›
I AM CURRENTLY IN TRAINING AND DON’T YET HAVE MY TRAINING CERTIFICATE.
Ask your current program if you will get your certificate before your Vanderbilt start date.
i.
If yes, go ahead and send the rest of the items above in the GME envelope and e-mail us a
copy of your certificate as soon as you get it (GME.Office@vanderbilt.edu).
ii.
If no, training certificate must be submitted to GME once certificate is obtained.
a.
Ask current program for and send us a letter that

states you completed or will complete training in the program,

includes your dates of training, AND

is signed by your current Program Director.
b.
make yourself a note to submit to the GME office once received.
Page ii
›
I DON’T HAVE AN ACTIVE TENNESSEE MEDICAL LICENSE.
GME does not require you to have a medical license or personal DEA # while in training in TN
(though full license IS required for moonlighting). More information here: http://vanderbi.lt/dea
I LOST/DON’T HAVE THE ENVELOPE ADDRESSED TO GME.
Use this address on any envelope: GME Office, 2215 Garland Ave, 201 Light Hall, Nashville, TN
37232-5283.
›

I completed this task.
EMAIL TO GME-CV
1. Update your CV and email to Audrey.Patrick@vanderbilt.edu.
Immediate

I completed this task.
RESUSCITATION
Check (http://vanderbi.lt/gmeresuscitation) for specific resuscitation standards per VUMC policy. Go to
“Resuscitation Status” in the House Staff Portal (https://gme.mc.vanderbilt.edu/gmeportal) and follow
these steps.
1. Indicate your current resuscitation training status
2. Upload your current course completion cards. Approved Agencies for Resuscitation Training can be
found: (http://vanderbi.lt/gmeresuscitation) or (http://vanderbi.lt/gmeresdocs). Beware of
resuscitation courses that are offered for a fee and are entirely online. They are a scam and not
approved to meet VUMC requirements.
3. You are encouraged to obtain the required Resuscitation training prior to arriving at Vanderbilt. If you
are unable to obtain the required training in advance, please register for resuscitation training via the
portal. Please note that ACLS and/or PALS do NOT satisfy the BLS-CPR training requirement. All
physicians are required to have current BLS-CPR certifications.

I completed this task.
IMMIGRATION VISAS
› I AM AN INTERNATIONAL INCOMING HOUSE STAFF ON OR NEEDING AN IMMIGRATION VISA.
› I AM SEEKING A J-1 VISA.
Work with GME and ECFMG to obtain the necessary immigration documents. Contact GME
(GME.Office@vanderbilt.edu) to begin the process.
› I NEED AN H-1B, E-3 OR O-1 VISA STATUS.
Contact your Program Coordinator to begin the process. Once the Program Coordinator
submits your information, you will receive a follow up email from VUMC Immigration
Service’s Partner, Fragomen, Del Rey, Bernsen & Loewy, Immigration Law attorneys. This
email will direct you to an online process to complete the application via the Vanderbilt
Immigration Home Page.
› I HAVE GENERAL QUESTIONS ABOUT MY IMMIGRATION STATUS OR UPCOMING CHANGES TO STATUS WHEN
BEGINNING RESIDENCY/FELLOWSHIP TRAINING.
Contact VUMC Immigration Services at immigration.vumc@vanderbilt.edu. Your question
will be directed to the appropriate area for response. Please note that guidance can be
provided on immigration matters related to Vanderbilt but cannot be provided on general
immigration.

I completed this task or I am not an international or needing an immigration visa.
SCRUBS
Go to “Order Scrubs” in the House Staff Portal. (https://gme.mc.vanderbilt.edu/gmeportal) and follow
the directions to order scrubs.

I completed this task.
Page iii
WHITE COATS
›
I AM ENTERING AS AN INTERN/RESIDENT.
Go to “Order Coats” in the House Staff Portal (https://gme.mc.vanderbilt.edu/gmeportal) and follow
the directions to request your white coats.
›
I AM ENTERING AS A CLINICAL FELLOW.
Your coats will be ordered by your program.

I requested my white coats or I am entering as a clinical fellow.
Immediate
NPI (NATIONAL PROVIDER IDENTIFIER) NUMBER
›
I HAVE AN NPI NUMBER.
Go to “Update NPI Number” in the House Staff Portal (https://gme.mc.vanderbilt.edu/gmeportal )
and enter your NPI Number.
›
I DON’T HAVE AN NPI NUMBER.
i. Go to www.mc.vanderbilt.edu/gmeNPI and follow the instructions to apply for one. Be sure
to choose type 1 (individual).
ii. Once you have received your NPI number, go to “NPI Number” in the House Staff Portal
(https://gme.mc.vanderbilt.edu/gmeportal) and enter it.

I completed this task.
I-9 PROCESS – STEP 1
Begin your Form I-9 (Employment Eligibility Form) here: (www.mc.vanderbilt.edu/gmei9). All employees
MUST complete the I-9 process.

I completed Step 1 on the GME I-9 webpage (www.mc.vanderbilt.edu/gmei9).
UPDATE PERSONAL INFO
Go to “Update Personal Info” in the House Staff Portal (https://gme.mc.vanderbilt.edu/gmeportal) and
make sure all personal/contact information we have for you is correct. Make updates here anytime your
info changes (i.e. phone number, address, etc.).

I completed this task.
ORIENTATION DATES
On your calendar, block the dates June 24, 27, and 28, 2016 for House Staff Orientation.
›
I AM ENTERING AS A PGY2 OR ABOVE AND WILL HAVE UNAVOIDABLE DUTIES FOR MY CURRENT TRAINING PROGRAM
DURING THOSE DATES AND WILL NOT BE ABLE TO COME TO ORIENTATION.
E-mail GME (GME.Office@vanderbilt.edu) and your Program Coordinator about your situation.

I completed this task.
NAME CHANGE
›
I HAVE/WILL HAVE A LEGAL NAME CHANGE BETWEEN THE DATE I COMPLETED MY APPLICATION AND MY START DATE.
i. Let us know (GME.Office@vanderbilt.edu) your new legal name (“First:____, Middle:____,
Last:_____”).
April

I completed this task or have not and will not have a legal name change in the time between
applying and my start date.
CHECK RECEIVED ITEMS
1. Go to “Pre-Employment - Items Received” in the House Staff Portal
(https://gme.mc.vanderbilt.edu/gmeportal).
2. Follow up on items that GME hasn’t received.

I completed this task.
Page iv
April
CHECK VANDERBILT E-MAIL
Go here (https://email.vanderbilt.edu) to check your Vanderbilt e-mail at least weekly. Important e-mails
from GME and other departments will be sent to your Vanderbilt e-mail.
Instructions for email name changes: Go to http://www.vanderbilt.edu/accessvu/existing , Click "Enter
PII", Log in and Update the personal information.
Once completed, send an email to it@vanderbilt.edu. In the email, explain that you just updated your PII
and you now need to update your Display Name and Email address.

INTERNATIONAL TAX
› I AM AN INTERNATIONAL INCOMING HOUSE STAFF.
Watch your e-mail for instructions from the International Tax Office to access the international tax
database, and follow those instructions.
› I HAVE QUESTIONS ABOUT INTERNATIONAL TAX.
Contact the International Tax Office (ITOVUMC@vanderbilt.edu).

April/May
I am checking my Vanderbilt e-mail at least weekly.
I completed this task or I am not an international incoming house staff.
IMMUNIZATION & SCREENING FORM DO NOT MAIL OR EMAIL FORMS
1. Electronically gather copies of any immunization/test records that meet the criteria listed on the
Immunization and Screening Form in this folder or here:
(www.mc.vanderbilt.edu/documents/gme/files/ImmunizationandScreeningForm.pdf)
2. Fill out the Immunization and Screening Form.
3. Upload the completed form and corresponding documentation to the New Employee website link:
https://healthandwellness.vanderbilt.edu/submit-records/
› I DON’T HAVE ALL REQUIRED IMMUNIZATIONS/TESTS THAT ARE LISTED ON THE IMMUNIZATION AND SCREENING FORM.
Include documentation for all immunizations and tests you have. Occupational Health will provide
the remaining necessary immunizations/tests during Orientation at no cost to you.

I completed this task.
I-9 PROCESS – STEPS 2 and 3
Complete Steps 2 and 3 outlined on the GME I-9 webpage (www.mc.vanderbilt.edu/gmei9).
May

I completed this task.
ACCESS TO INTERIM HEALTH INSURANCE
›
I NEED INTERIM HEALTH INSURANCE COVERAGE PRIOR TO MY START DATE AT VANDERBILT
i. Your health insurance coverage at Vanderbilt will begin on your start date (start date/hire
date is July 1st for most unless you are starting “off-cycle”). Vanderbilt GME is providing
advanced access to information regarding interim coverage you can purchase if desired.
ii. If you need interim Health Insurance Coverage prior to your start date at Vanderbilt please
contact Marsh and McLennan Agency at 1-844-854-9142 and indicate you are an incoming
House Staff member at Vanderbilt and will need quotes for short-term interim health
insurance coverage prior to your start date.

I completed this task or don’t need interim health insurance coverage. I am aware that my health
insurance benefits at Vanderbilt will begin on my start date/hire date.
IMMEDIATE ACTION ITEMS
Any item in the Immediate Action section that has not been completed is now past due. Double check
to make certain you completed all immediate action items.

I completed this task.
Page v
CHECK RECEIVED ITEMS
1. Go to “Pre-Employment - Items Received” in the House Staff Portal
(https://gme.mc.vanderbilt.edu/gmeportal).
2. Follow up on items that GME hasn’t received.
May

I completed this task.
CHECK VANDERBILT E-MAIL
Go here (https://email.vanderbilt.edu) to check your Vanderbilt e-mail at least weekly.

I am checking my Vanderbilt e-mail at least weekly.
ONLINE REQUIRED TRAINING MODULES
All trainings must be completed BEFORE you begin clinical service. Go to (http://vanderbi.lt/gmetrn) and
complete all training modules currently assigned to you. Please allow plenty of time as there will be
multiple assignments depending on your program. This includes Inpatient Clinical Systems Training, which
will take an additional 2 hours.

I completed this task.
IMMEDIATE ACTION ITEMS
Any item in the Immediate Action section that has not been completed is now past due. Double check
to make certain you completed all immediate action items.

I completed this task.
CHECK RECEIVED ITEMS
1. Go to “Pre-Employment - Items Received” in the Portal (https://gme.mc.vanderbilt.edu/gmeportal).
2. Follow up on any items that GME still hasn’t received.
June/Pre-Orientation

I completed this task.
CHECK VANDERBILT E-MAIL
Go here (https://email.vanderbilt.edu) to check your Vanderbilt e-mail at least weekly.

I am checking my Vanderbilt e-mail at least weekly.
NEW HOUSE STAFF WEBPAGE
Go to the New House Staff webpage on the GME website and review the information there
(www.mc.vanderbilt.edu/newhousestaff).

I completed this task.
ID CARD
Go to the Medical Center Card Services Office (D-2107 Medical Center North) to have your picture taken
and ID card made (open 8:30am-1pm and 2pm-4:30pm, Monday-Friday).
› I WON’T BE ABLE TO GO TO THE CARD SERVICES OFFICE BEFORE ORIENTATION.
You MUST have your ID card by your start date, so plan to go to the Card Services Office the week of
Orientation to have your picture taken and ID card made.

I completed this task or will have my ID card made the week of Orientation.
UPDATE PERSONAL INFO – LOCAL ADDRESS
Go to “Update Personal Info” in the House Staff Portal (https://gme.mc.vanderbilt.edu/gmeportal) and
make sure all personal/contact information we have for you is correct, especially your local address if you
now have it.

I completed this task and confirmed my local Nashville address.
HOUSE STAFF MANUAL
Page vi
Review the House Staff Manual (policy manual) on the GME website here:
http://www.mc.vanderbilt.edu/documents/gme/files/HSManual.pdf .
› I AM CONSIDERING DOING SOME MOONLIGHTING WORK.
Be sure to read the “Extracurricular Professional Activity (Moonlighting)” policy and get formal
written approval before moonlighting. Forms are on the GME website here:
www.mc.vanderbilt.edu/root/vumc.php?site=gme&doc=13511.

I completed this task.
RESPIRATOR FITTING
1. Review info about respirator fitting here: www.safety.vanderbilt.edu/resources/hcs_respirator.htm.
2. Complete the Particulate Respirator Approval Form in this folder or here: DO NOT MAIL
https://www4.vanderbilt.edu/safety/respirator/pdf/appendix_3_n95_initial_fit-testing_form.pdf).
› I HAVE FACIAL HAIR.
Your facial hair might disqualify you from fit-testing. Be sure to read this:
www.safety.vanderbilt.edu/clinical/fittest_facialhair.pdf.
June/Pre-Orientation

I completed this task.
PARKING
1. Review Information on Your Permit to Park in this folder or here:
(http://www.mc.vanderbilt.edu/documents/gme/files/PARKINGinstructions.pdf)
2. Fill out the Parking Agreement in this folder or here : DO NOT MAIL
(http://www.mc.vanderbilt.edu/documents/gme/files/PARKINGagreement.pdf)

I completed this task or won’t be parking at Vanderbilt (you can register for parking later if
needed).
CREDO and PATIENT AND FAMILY PROMISE
Review Credo Behaviors (www.mc.vanderbilt.edu/documents/Elevatesite/files/CredoLetter.pdf) and the
Patient and Family Promise (www.vanderbilthealth.com/main/42103).

I read the Credo Behaviors and the Patient and Family Promise and understand I am accountable
for knowing and exhibiting these behaviors.
BRING TO ORIENTATION DO NOT MAIL
Collect all of these items in one place so you can bring them to Orientation.
1.
Particulate Respirator Approval Form
2.
New Employee Information Form
(http://hr.vanderbilt.edu/forms/documents/NewEmployeeInfoForm.pdf)
3.
W-4 (http://hr.vanderbilt.edu/forms/2016W4.pdf)
4.
Identification documents for completing your I-9
(http://hr.vanderbilt.edu/i9/documents/I9-Acceptable-Documents.pdf).
5.
Parking Agreement (Make sure you fill in license plate number or take a photo of your license plate
for reference.)
6.
State-issued Vehicle Registration (any state)
7.
Campus map (in this folder) or use an interactive web version here: www.vanderbilt.edu/map/).
8.
If your program rotates to the VA, two official IDs for VA Registration (i.e. Driver’s License and
Vanderbilt ID with full legal name – no nicknames) Check with your program coordinator if you don’t
know.

I completed this task.
ONLINE REQUIRED TRAINING MODULES
All trainings must be completed before you begin clinical service. Go to http://vanderbi.lt/gmetrn
again and complete any additional training modules now assigned to you.

I completed this task.
Page vii
TNCSMD
Register with TNCSMD (Tennessee Controlled Substances Monitoring Database). Follow the instructions
here: http://vanderbi.lt/gmetncsmd. YOU WILL NOT BE ABLE TO REGISTER UNTIL YOUR START DATE.
Start Date

I completed this task.
C2HR - DIRECT DEPOSIT and BENEFITS ENROLLMENT
1. Go to C2HR (Connect to Human Resources): www.vanderbilt.edu/c2hr.
2. Select “Direct Deposit” and follow the instructions to set up direct deposit for your paycheck. You
will need the following information for each account (8 max.) into which you want your check
deposited: Bank name, Bank transit number, Bank account number, Account type.
3. Select “Benefits Enrollment” and follow the instructions to enroll for your benefits.
› I NEED MORE INFORMATION ABOUT BENEFITS OR ENROLLMENT.
Go to the HR Benefits page here: http://hr.vanderbilt.edu/benefits/index.php#a2z.
› I HAVE QUESTIONS ABOUT DIRECT DEPOSIT, BENEFITS, OR OTHER HUMAN RESOURCES ITEMS.
Contact the Employee Service Center: 615-343-7000 or human.resources.vumc@vanderbilt.edu.

I completed this task.
TRAINING CERTIFICATE
If you now have a training certificate for recently completed internship/residency/fellowship and haven’t
already provided a copy to GME, do so now by emailing to GME.Office@vanderbilt.edu
MEDICARE PART D
If you do or might order or refer for Medicare Part D, you will need to enroll or update your information
with Medicare. Follow the instructions here:
http://www.mc.vanderbilt.edu/root/vumc.php?site=gme&doc=48516 YOU WILL NOT BE ABLE TO
REGISTER UNTIL YOUR START DATE.

I completed this task.
That’s all for now! We will keep in touch about any pending items and additional tasks before your start date and
throughout your training. If you have questions about your transition to Vanderbilt house staff, you can e-mail
(GME.Office@vanderbilt.edu) or call (615-322-4916). See you at Orientation! - GME Office
Page viii
Pre-Arrival Immunization and Screening Form
Upload documentation of any immunizations or tests to:
https://healthandwellness.vanderbilt.edu/submit-records/
Welcome to Vanderbilt! The Occupational Health Clinic is dedicated to protecting your health while you
work. To meet the Medical Center’s requirements, you will need documentation for the following
immunizations and/or tests before beginning work. If you do not have complete records, Occupational
Health will provide any needed immunizations or tests during orientation.
VUMC IMMUNIZATION/SCREENING REQUIREMENTS
Hepatitis B: If you have the potential to come in contact with human blood or
body fluids as part of your employment here, you must document either
A. A completed series of 3 hepatitis B vaccines, or
B. A hepatitis B vaccine series in progress, or
C. Laboratory evidence of immunity to hepatitis B, or
D. Informed refusal of the vaccine (by signing declination form at the Vanderbilt
Occupational Health Clinic.)
Varicella: A history of chickenpox infection is not adequate. You need either
A. Laboratory evidence of varicella immunity (with date and result), or
B. Documentation of two doses of varicella vaccine.
MMR
Measles (rubeola): If born on or after 1/1/1957, documentation of either
A. Two live measles or MMR vaccines at least a month apart, after the first birthday, or
B. Laboratory evidence of immunity to rubeola (date and result)
Mumps: If born on or after 1/1/1957, documentation of either
A. One live mumps or MMR vaccine after the first birthday, or
B. Laboratory evidence of immunity to mumps (date and result)
Rubella (German measles): (Regardless of birth date)
A. Documentation of a rubella or MMR vaccine after the first birthday, or
B. Laboratory evidence of immunity to rubella (date and result)
Tetanus/Diphtheria/Pertussis: (Optional) Documentation of a Tdap within past 10 years.
Tdap is a form of tetanus/diphtheria vaccine with pertussis (whooping cough) protection. Tdap
is strongly recommended for healthcare workers. One of your adult Td boosters should be in the
form of Tdap.
Tuberculosis:
A. Written documentation of 2 negative TB skin tests within the past 12 months, with the
most recent being within the past 3 months, or
B. A negative IGRA blood test (such as QuantiFERON or T-Spot) within the last 3
months, or
C. If you have a prior positive skin test (or positive IGRA such as QuantiFERON or Tspot) you must have a chest X-ray, no more than 6 months prior to your start date.
NOTE: If you have had BCG vaccine, you ARE still required to undergo TB skin testing or IGRA
blood testing, unless you have also had a previous positive TB skin test or IGRA.
M:\Shared\GME\Orientation\Orientation Packet\2016 Orientation Packet\New Immunization Record for Pre-Arrival 2016.doc
If you have a previous positive skin test (>10mm induration) or a positive IGRA (e.g
QuantiFERON or T-spot), complete the information below and upload to the
occupational health website:
Positive PPD History
PPD History
Date of positive TBST___________ Date of last negative TBST__________
Exposure History
Born or lived outside USA
N___Y___ Country________________
Community exposure to active TB N___Y___
Date_________
Previous employment exposure N___Y___
Date_________
VU occupational exposure
N___Y___
Date_________
Source Pt name______________________ MR#______________
Is there direct patient contact
N____Y________________________
Symptom History: Have you experienced any of the following symptoms within the past 6
months?







Unplanned weight loss-----------------------------------------------------------Y / N
Night sweats------------------------------------------------------------------------Y / N
Fever lasting several weeks----------------------------------------------------Y / N
Frequent cough in the absence of a cold or flu----------------------------Y / N
Coughing up blood or blood streaked sputum-----------------------------Y / N
Chest pain or pain in the chest when taking a breath--------------------Y / N
Shortness of breath/difficulty breathing--------------------------------------Y / N
Treatment History
BCG within last 5 years N____Y____
Prior TB treatment
N___Y___ Date________ # Months treated_______
I certify that the above information set forth in this document is true and complete to the best of my
knowledge.
_____________________________________
Signature
________________
Date
-------------------------------------------------------------------------------------------------------------------------------------------
If you have pertinent Vanderbilt records, let us know:
□ I have worked at Vanderbilt Medical Center previously – please review my old employee records.
□ I have had labs/vaccines as a patient or student at Vanderbilt - please review my medical records.
Signature required: _______________________________________________
M:\Shared\GME\Orientation\Orientation Packet\2016 Orientation Packet\New Immunization Record for Pre-Arrival 2016.doc
N-95 PARTICULATE RESPIRATOR APPROVAL FORM
VANDERBILT OCCUPATIONAL HEALTH CLINIC
VANDERBILT ENVIRONMENTAL HEALTH & SAFETY
Respiratory Protection Program
Section 1 - Health Questionnaire
To be completed by employee
Name (Please print)________________________________
Yes
No
Yes
No
1. Do you smoke tobacco?
2. Have you ever had any of the following
conditions? (indicate yes or no for each)
a. Seizures (fits)
b. Diabetes (sugar disease)
c. Allergic reactions that interfere with
your breathing
d. Claustrophobia (fear of closed-in places)
e. Trouble smelling odors
3. Have you ever had any of the following
pulmonary or lung problems?
a. Asbestosis
b. Chronic bronchitis
c. Emphysema
d. Lung cancer
e. Silicosis
f. Chest injuries or surgeries
g. Asthma as an adult
h. Pneumonia in the last month
i. Tuberculosis (active disease)
k. Any other lung problem that you've
been told about:
4. Do you currently have any of these
symptoms of pulmonary or lung illness?
a. Shortness of breath
b. Shortness of breath with light activity
c. Shortness of breath with strenuous activity
d. Cough that produces thick sputum or blood
e. Cough lasting longer than 3 weeks
f. Wheezing
g. Wheezing that interferes with work
h. Any other symptoms that may be related
to lung problems
5. Have you ever had any of the following
cardiovascular or heart problems?
a. Heart attack
b. Stroke
c. Angina (chest pain)
Yes
Yes
Yes
No
No
No
5. (Continued)
d. Heart Failure
e. Irregular heart beat
f. Swelling in your legs or feet
(not caused by walking)
g. High blood pressure
h. Any other heart problems
6. Have you ever had any of the following
cardiovascular or heart symptoms?
a. Frequent pain or tightness in your chest
b. In the past two years, have you noticed
your heart skipping or missing a beat?
c. Heartburn or indigestion that is not
related to eating
d. Any other symptoms that may be related
to heart or circulation problems
7. Do you currently take medication for
any of the following problems?
a. Breathing or lung problems
b. Heart trouble
c. Blood pressure
d. Seizures (fits)
8. If you've used a respirator, have you
ever had any of the following problems? (If
you've never used a respirator, skip
question 8 and go to question 9.)
a. Eye irritation
b. Skin allergies or rashes
c. Anxiety
d. General weakness or fatigue
e. Any other problem that interferes with
your use of a respirator
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
9. Would you like to talk to the health care
professional who will review this survey?
EMPLOYEE SIGNATURE________________________________________________________Date___________
-------------------------------------------------------DO NOT WRITE BELOW THIS LINE-----------------------------------------------------------COMMENTS________________________________________________________________ OHC Initials________
VEHS\shared\hcs\tb resp prg\current fit test documents
revised: 12/15/2015
N-95 PARTICULATE RESPIRATOR APPROVAL FORM FOR FIT TESTING
VANDERBILT OCCUPATIONAL HEALTH CLINIC/VANDERBILT ENVIRONMENTAL HEALTH & SAFETY
Section 2 – Employee Information – To be completed by employee: (Please PRINT)
PRINT Name:
____________________________
____________________________
____________________________
First
Middle
Last
Department:
Supervisor:
Today’s Date:
Date of Birth:
-------------------------DO NOT WRITE BELOW THIS LINE---------------------Section 3 – Medical Provider’s Written Opinion—To be completed by Occupational Health
I.
You were evaluated to determine if you are physically able to perform assigned task(s)
requiring the use of a particulate filtering respirator (i.e. N-95).
II.
Your evaluation revealed the following:
[ ]
A. You are approved to wear a particulate respirator without restrictions and can
progress to the next step of training and equipment fit testing.
[ ]
B. You are approved to wear a particulate respirator with the following restriction(s):
_____ Do not wear the respirator if wheezing or short of breath.
_____ Notify supervisor if you have difficulty wearing the respirator.
[ ]
C. _____ You are not approved to wear a particulate respirator.
III.
Your next respirator medical evaluation is due:
 If you develop a serious health condition that interferes with using a respirator.
 If there is a change in the workplace condition (e.g., physical labor, protective clothing,
temperature) that may substantially increase your physiological work effort.
This faculty/staff member was notified of the results of this evaluation and of any further evaluation or
treatment recommended.
(Provider Signature)
(Date)
Section 4 – Respirator Issuance—To be completed by Environmental Health & Safety
RESPIRATOR:
Brand and Model Number:
Size:
[
] 3M 1870+ (tri-fold, one size/all fit)
[
] Small
[
] 3M 1860S (blue molded)
[
] Medium
[
] 3M VFlex 1805 (larger, one size/all fit)
[
] Large
[
] Other: ____________________________
FITTING:
[
] Training for Use Completed by Employee
[
] Satisfactory Qualitative Bitrex Fit Test
[
] Satisfactory Qualitative Saccharin Fit Test
[
] Satisfactory Portacount fit test
[
] Satisfactory Positive Pressure Fit Check Test
[
] Could not complete fit testing process
[
] Declined to participate in fit testing process
Approval Signature:
Date:
___Entered into VOHIS
Not listed in database:___________(date attempted)
___Original sent to OHC
No longer in program:___________(date)
Comments:__________________________________________________________________________________________
…VEHS\shared\hcs\tb resp prg\current fit test documents
revised: 3/8/2016
New Employee Information Form _____________________________________________________ ( _________ ) _________________________________ Employee ID or Social Security Number ________ / __________ / _________ Home Phone Number Date of Birth _____________________________________________________ ______________________________________________ ____________ Last Name First Name M.I. _____________________________________________________ ______________________________________________ ____________ _____________________ Home Mailing Address City State ZIP GENDER:  Male  Female  I do not wish to disclose MARRIED:  Yes  No Race/Ethnic Group Are you Hispanic or Latino? (Check the appropriate box) 
 Yes  No A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race Please select one or more races from the list below. (Check all that apply) A person having origins in any of the original peoples of Europe, North Africa, or the Middle East  White  Black or African American A person having origins in any of the Black racial groups of Africa  American Indian/Alaskan Native A person having origins in any of the original peoples of North, Central or South America and (not Hispanic or Latino) who maintains tribal affiliation or community attachment  Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. This area includes China, Japan, Korea, Thailand, and Vietnam.  Pacific Islander A person having origins in any of the original peoples of the Pacific Islands, the Philippine Islands, Samoa, Hawaii, and Guam.  I do not wish to disclose Military Information (Check all that apply)  Not applicable  Disabled Veteran a veteran 1) of the U.S. military ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or 2) who was discharged or released from active duty because of a service‐connected disability  Vietnam‐Era Veteran a veteran whose active military, naval or air service was during the period August 5, 1964 through May 7, 1975 who served on active duty for more than 180 days and was discharged with other than a dishonorable discharge or because of a service‐connected disability  Other Protected Veteran a veteran who served on active duty in the U.S. military ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense  Armed Forces Service Medal Veteran a veteran who, while serving on active duty in the U.S. military ground, naval or air service participated in a U.S. military operation for which an Armed Forces Service Medal was awarded pursuant to Executive Order 12985 (61 FR 1209, 3 CFR, 1996 Comp., p. 159)  Recently Separated Veteran a veteran during the three‐year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military ground, naval or air service Military Status:  Active Reserve  Inactive Reserve Separation Date _________ / __________ / __________ Vanderbilt is committed to principles of equal opportunity and affirmative action. Vanderbilt is committed to a policy of non‐discrimination in employment and education and complies with the requirements of the Americans with Disabilities Act of 1990 (ADA) and the Rehabilitation Act of 1973, which prohibit discrimination against persons with disabilities. If you have questions or concerns pertaining to accommodation services for people with disabilities contact the Disability Program Director, Opportunity Development Center, VU Station B #351809, 2301 Vanderbilt Place, Nashville, TN 37235‐1809; phone 615.322.4705 (V/TDD); fax 615.343.0671; Web site www.vanderbilt.edu/odc. ______________________________________________________________ __________________________________ Signature Date Processing Office Use Only Pay Group _________________ Employee ID # ______________ Entered by _________________ Audited by _________________ Date Received in Processing Mail form to: Vanderbilt HR Processing, PMB #407718, 2301 Vanderbilt Place, Nashville, TN 37235‐7718 Deliver form to: HR Processing, 975 Baker Building, Nashville, TN 37203 7/10
2016 GME Resident/Fellow
Parking Information
Your parking is in South Garage – Level 5 and above only.
Look for our Registration Table at Orientation!!
The following items are required:
 VUMC I. D. Badge
 Current State Vehicle Registration or Picture of your
license plate.
 Completed Parking Agreement
VUMC Parking &
Transportation
Services
615-936-1215 Press
Option 3
Vanderbilt University
Medical Center requires
all vehicles be
registered with VUMC
Parking &
Transportation Services.
After Your Orientation,
Parking Permits are
Required.
Go to: www.mc.vanderbilt.edu/parking to review all your parking
privileges, rules and regulations.
If you miss us at Orientation, Visit the VUMC Parking Permit Office
located in East Garage, Ground Level. Hours 7:30 AM-4:30 PM
Monday – Friday.
OFFICE USE ONLY
Permit #
GME PARKING AGREEMENT (please print clearly)
DATE: ______________
Location
Gate Card #
NAME: _______________________________________________________
Exp. Date
CONTACT PHONE #: ___________________________________________
Classification
LAST 4 DIGITS OF SS#: ______________
HOME ADDRESS:_______________________________________________
Employee ID#
CITY:____________________________ST:_________ZIP CODE:__________
___________FELLOW
or
___________RESIDENT
Payment Type
VANDERBILT EMAIL ADDRESS (if known):___________________________________________
NAME OF DEPARTMENT:_______________________________________________________
The privilege of parking in the Vanderbilt Medical Center Parking Facilities or at 100 Oaks Medical Center
(staff area) is subject to the following terms and conditions. Note: VUMC Parking & Transportation reserves
the right to control parking and move your designated parking space as needs demand.
PLEASE READ & INITIAL
1
The term of this agreement shall commence on the date of this agreement and continue
there after until Permit is returned to the VUMC Permit Office. Owner or Operator assumes
responsibility for articles left in the vehicle, loss due to theft, or vehicle damage by fire,
vandalism, collision, or otherwise.
2
Licensee agrees to abide by all rules and regulations stated on the Vanderbilt University
Medical Center Parking website at: www.mc.vanderbilt.edu/parking
3
Licensee agrees to have permit fees deducted from his/her wages and applied toward their
account with VUMC Parking & Transportation. Parker agrees to pay for fines and fees if
payment cannot be payroll deducted. The cost for monthly parking; however, is paid for by
GME.
VEHICLE INFORMATION
LICENSE PLATE: _________________
MAKE:
________________
STATE:
_______________________
MODEL:
________________
COLOR:
_______________________
YEAR:
_______________________
STYLE:
(circle one)
Two-Door
Four-Door
SUV
Truck
Van
Motorcycle
SIGN HERE
X______________________________________________ I understand Vanderbilt Medical
Center Rules and Regulations and the terms as stated in this agreement.
Updated 2/26/16 Resident Agreement
The Vanderbilt
Clinic
Courtyard
Cafe
Critical Care
Tower
Medical Center Drive
Central Garage
Oxford
House
Dayani
Center
Henry Joyce
Cancer Clinic
Jess Neely Drive
Robinson Research Building
P
21st Ave. South
The Village at Vanderbilt
Patient Parking
Light Hall
Garland Avenue
MRB IV
uth
So
Free
Electron
Laser Center
Round
Wing
Langford
Orientation
&Auditorium
McDonaldʼs
GME
Office
Vanderbilt
University Hospital
Medical Center East
Medical Center East
South Tower
Bill Wilkerson
Center
East garage
21st Ave. South
North Tower
P
Peabody
Admin
Building
Medical Arts
Building
Stevenson
Center
Medical Center North
Card
Services
Office
Vanderbilt Institute
for
Imaging Science
Vanderbilt
Kennedy
Center
MRB
III
Frist Hall
Godchaux
Hall
Edgehill Ave.
P
P
Monroe Carell Jr.
Childrenʼs
Hospital at
Vanderbilt
Pierce Avenue
Childrenʼs Way
P
Blakemore Ave.
Vanderbilt-Ingram Cancer Center
Food Court
Vanderbilt
Stallworth
Rehabilitation
Hospital
Preston
Research Building
P
23rd Ave. South
ve
hA
t
24
VA Research &
Education
P
Vanderbilt Eye
Institute
University
Club
Veterans
Administration
Medical Center
VA Parking
Garage
Parking
P
Highland Drive
VA
Parking
Eskind
Library
Pierce Avenue
Patient/Visitor
Parking
Psychiatric
Hospital at
Vanderbilt
ue
South
Garage
Olin
Hall
en
Av
24th Avenue South
5
252 t
s
We
End
Stadium
Club
d
En
25th Avenue
Staff Garage
Memorial
Gym
st
We
25th Avenue South
Blair
School of Music
Martha Ingram
Performing
Arts Center
Marriott at
Vanderbilt
19