Graduate Medical Education

Graduate Medical Education
Outgoing Rotation/Elective Agreement Request Form

Is this a required or elective rotation?
Is there a current agreement
 in place for this rotation/elective?

Residents Rotating From:
Residents Rotating To:
UPHS Department:
UPHS Subspecialty (if any):
Outside Department:
Outside Subspecialty (if any):
Title of Program:
Participating Institution
PI Program Director: First name:
Last name:
PI Title:
PI Director E-mail:
PI Address Line 1:
PI Address Line 2 (if any):
PI City:
PI State:
PI Zip Code:
PI Telephone:
PI Fax:
PI Program Coordinator:
PI Coordinator Email:
Sponsoring Institution - UPHS
SI Program Director First name:
Last name:
SI Title:
SI Director E-mail:
SI Address Line 1:
SI Address Line 2 (if any):
SI City:
SI State:
SI Zip Code:
SI Telephone:
SI Fax:
SI Program Coordinator:
SI Coordinator Email:
Housestaff Information
Max number of residents rotating at
participating institution at any one time:
Rotation status
Duration of each rotation:
Effective dates: From:
Education goals and objectives (please upload a Word document):
  Please email Goals and Objectives in Word document format to
Who will cover salary?
Who will cover malpractice?
Faculty's responsibilities for teaching, supervision and formal evaluation of the Program Resident.
Comments (if any)
Contact Information
Name of person completing this form:
Telephone number:


If you have questions or concerns, please contact:
University of Pennsylvania Health System
Jordan Medical Education Center (JMEC)
3400 Civic Center Blvd, 6th Floor, South Pavilion Expansion
Philadelphia, Pennsylvania 19104
PH: (215) 662-3957
Fax: (215) 615-4111