Graduate Medical Education
Outgoing Rotation/Elective
Agreement Request Form


Is this a one-time rotation and/or elective?:
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:

Sponsoring Institution - UPHS
	Program Director(s):
	Title:
	Director E-mail:
	Address 1:
	Address 2 (if any):
	City:
	State:	Zip Code:
	Telephone:	Fax:
	Program Coordinator:
	Coordinator E-mail:

Participation Institution
	Program Director(s):
	Title:
	Director E-mail:
	Address Line 1:
	Address Line 2 (if any):
	City:
	State:	Zip Code:
	Telephone:	Fax:
	Program Coordinator:
	Coordinator E-mail:

Housestaff Information

Max Number of Residents Rotating a Participation Institution At Any One Time:

Name(s) of Resident(s):

Employment Status:

Duration of Each Rotation:

Effective Dates: dd/mm/yyyy

From:

To:

Please copy and paste from a Micrsoft Word document in the area provided below:

A. Educational Goals and Objectives. Objectives must be formatted to fit the ACGME's Six General Competencies. (for example, click here)

B. Terms of Agreement (ex. Who will cover salary and malpractice?)

C. Resident Compensation (if applicable)

D. Faculty’s responsibilities for teaching, supervision and formal evaluation of the Program Resident”.

E. Comments (if any)

Contact Information

Name of Person Completing This Form

Telephone Number

If you have questions or concerns, please contact:

Graduate Medical Education Department
University of Pennsylvania Health System
3400 Spruce Street, 1 Maloney
Philadelphia, PA 19104
PH: (215) 662-3957
Fax: (215) 615-4111
Email: annamarie.grady@uphs.upenn.edu

Graduate Medical Education Outgoing Rotation/Elective Agreement Request Form

Graduate Medical Education
Outgoing Rotation/Elective
Agreement Request Form