Departments and Services | For Patients | Research & Trials | Education | Find a Doctor

Search:

Graduate Medical Education
Outgoing Rotation/Elective
Agreement Request Form

 
Is this ACGME or NON-ACGME?
 
Is this a required or elective rotation?:
 
Is there a current agreement in place for this rotation/elective?:
 

If yes, enter the PennTract Contract Number:
 
Residents Rotating From:
Residents Rotating To:
 
UPHS Department:
UPHS Subspecialty (if any):
 
Outside Department:
Outside Subspecialty (if any):
 
Title of Program:
 
Resident's ACGME/Non-ACGME Program Name


Sponsoring Institution - UPHS
 
Program Director(s):

Include credentials
 
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):

Include credentials
 
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:
 
 
Employment Status:
 
 
Duration of Each Rotation:
 
 

Effective Dates: dd/mm/yyyy

 
 
From:
 
To:
 

A. Educational Goals and Objectives

Please email Goals and Objectives in Word document format to annamarie.grady@uphs.upenn.edu

B. Who will cover salary?

C. Who will cover malpractice?

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



About Penn Medicine   Contact Us   Site Map   Privacy Statement   Legal Disclaimer   Terms of Use

Penn Medicine, Philadelphia, PA 800-789-PENN © 2013, The Trustees of the University of Pennsylvania