Forms - GME

GME and Resident/Fellow Forms

1. Annual Program Review
   
2. Biographical/Graduate Registration Form
   
3. Clearance Packet for Residents (will be posted in May before departing residents and
   fellows leave at the end of June 2010)
   
4. Competency Form
   
5. Dependent Reimbursement Account Claim Form
   
6. Erlanger Access Card and Pin Code Request
   
7. Erlanger - Acknowledgement of Appropriate Use of the Internet Via Erlanger Computers
   
8. Erlanger Information Confidentiality Agreement
   
9. Erlanger Invision/Net Access/Electronic Signature/Internet Login Request
   
10. Erlanger Medical Library Usage Form
    
11. Erlanger Official Signature Form
    
12. Erlanger Parking Control Card Form
    
13. Health Insurance Application - COBRA (for exiting residents) - Will be mailed by CIGNA
    to residents after they leave.]
    
14. Health and Dental Insurance Enrollment or Change Form - RESIDENTS ONLY
    
15. Health Insurance Disclaimer Form
    
16. Health Statement
    
17. I-9 Employment Eligibility Verification
    a.  I-9 Form for Residents/Fellows
    b.  I-9 Acceptable Forms of Identification
    
18. Immunization Record
    
19. Initial Resident Letter of Agreement
    
20. Internal Review Forms
    a.  Internal Review Self Study - Word Document
    b.  Internal Review Assessment Methods Worksheet
    c.  Internal Review Resident Questionnaire - pdf
    
21. Internet Waiver Form
    
22. Life Insurance Application Form
    
23. Medical Reimbursement Account Claims Form
    
24. Moonlighting Application Form
    
25. NPI Online Application
    
26. Offsite Rotation Approval
    
27. OSHA Respirator Medical Evaluation Questionnaire
    
28. Outside Interest Disclosure Form
    
29. UT Personal Data Form (an interactive Excel document)
    
30. Respirator Fit Pre-Test Questionaire
    
31. TB Skin Test Form for Residents
    
32. Transitional Year Forms
    a.  Transitional Year Daily Sign-In Form 
    b.  Transitional Year Personal Day Off Form 
    c.  Transitiona Year Rotation Change Request Form 
    d.  Transitional Year Vacation/Conference Request Form
    e.  Transitional Years Mid-Month Form
    f.   Transitional Year Confidential Peer Evaluation Form 
    g.  Transitional Year Confidential Attending Evaluation of Resident Form
    h.  Transitional Year Chart Stimulated Review
    i.  Transitional Year Personal Educational Portfolio Form 
    j.  Transitional Year Spreadsheet Template
             
33. UT 403B Company List
    
34. Visa Applications
    a.  J-1 (ECFMG website)
       
35. Visiting Resident Application Form
    
36. Visiting Student Application Form for Non-Allopathic or International Students
    
37. W-4 Form
    
38. W-9 Form

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