USF HEALTH - Graduate Medical Education
Request for new Rotation / Site
Agreement/Contract
I.
DEMOGRAPHIC INFORMATION FOR THE PROPOSED PROGRAM
Program Name
Program Director
Accreditation Available
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☐ ACGME
☐ Other Accreditation: __________________
☐ Accreditation Exempt
Length of Program in Years
Total Number of Positions
If approved, number of trainees per PGY level in
involved:
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PGY1 Click here to enter text.
PGY2 Click here to enter text.
PGY3 Click here to enter text.
PGY4 Click here to enter text.
PGY5 Click here to enter text.
PGY6 Click here to enter text.
PGY7 Click here to enter text.
PGY8 Click here to enter text.
Is this a new Rotation?
(IF “YES”, complete the New Rotation Request Form)
Is this a New Site?
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
Start Date for the new Rotation and/or Site
Is this rotational experience required by ACGME?
(Please add wording from ACGME if required)
Physical address of the new rotation
Type of entity/facility
(i.e., private practice, hospital)
Who will be funding this rotation/site?
(GME will secure signatures)
II.
EDUCATIONAL PROGRAM INFORMATION
Provide a rationale for this new site or expanded rotation. The rationale must be educational
in nature and not based on service demands. E.g., how would the new rotation enhance the
learning environment, improve the experience on certain rotations, complement existing
programs, and further enhance the mission of the institution/university?
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What impact, if any, would there be if this new program was not approved?
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Are the faculty at the proposed site Board Certified in the required
area?
III.
☐ Yes
☐ No
STRATEGIC IMPACT
How does the addition of this site/rotation affect residents, faculty, GME, university, and
hospitals?
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IV.
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ATTACHMENTS & APPROVALS
Goals and Objectives of the rotation
Scope of practice for the level of PGY participating in this new
site/rotation
Curriculum for the rotation
Faculty roster with Board certification status and area
_____
_____
_____
_____
NOTE: If for an Unaccredited Fellowship Program, Signature must be obtained from
BOTH the Fellowship Director AND the Program Director for the specialty.
Signature
Fellowship Director’s Signature
Program Director’s Signature
Department Chair’s Signature
Completed forms should be returned to:
Charles Paidas, MD, MBA
Vice Dean, Graduate Medical Education
12901 Bruce B Downs Blvd., MDC41
Tampa, FL 33612
(or via e-mail to lsnell@health.usf.edu)
Date
The GME Office will ensure completion of the section below...
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AFFILIATED HOSPITAL/FUNDING SOURCE APPROVAL:
Chief Medical Officer Signature:
________________________________________
Affiliated Hospital / Funding Source: ________________________________________
Date:
________________________________________
(Additional Funding Source – if required)
Chief Medical Officer Signature:
________________________________________
Affiliated Hospital / Funding Source: ________________________________________
Date:
________________________________________
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Approved by GMEC (Date): _____________________________
January 2016