Penn Medicine Graduate Medical Education

Outgoing Rotation/Elective Agreement Request Form

Accreditation Status
Is this ACGME or NON-ACGME?	ACGMENON-ACGME * Please choose an option
Request Information
Is there a current agreement in place for this rotation/elective?	YesNo * Please choose an option
Residents Rotating From:	* Selection is required.
Residents Rotating To:	* Rotating to institution is required.
UPHS Department:	* UPHS department is required.
UPHS Division/Subspecialty (if any):
UPHS Program:	* Required
Outside Department:	* Outside department is required.
Outside Subspecialty (if any):
Participating Institution - External Site
Program Director:	First name:
	Last name:
	Credentials:
Address Line 1:	* Address is required.
Address Line 2 (if any):
City:	* City is required.
State:	* State is required.
Zip Code:	* Zip code is required.
Sponsoring Institution - UPHS
UPHS Program Director	First name: * First name is required.
	Last name: * Last name is required.
	Credentials:
UPHS Director E-mail:	* Email is required.
UPHS Address Line 1:	* Address is required.
UPHS Address Line 2 (if any):
UPHS City:	* City is required.
UPHS State:	* State is required.
UPHS Zip Code:	* Zip code is required.
UPHS Program Coordinator:	* Program coordinator is required.
UPHS Coordinator Email:	* Coordinator email is required.
Housestaff Information
Max number of residents rotating at participating institution at any one time:	* Number of residents is required. * Invalid number.
Rotation status:	Full TimePart Time * Please choose an option
Duration of each rotation:	* Duration is required.
Effective dates:	From: * Invalid date. To: * Invalid date.
Education goals and objectives: Please email Goals and Objectives in Word document format to Annamarie.Grady@Pennmedicine.upenn.edu.
Who will cover salary? * Required.
Who will cover malpractice? * Required.
Faculty's responsibilities for teaching, supervision and formal evaluation of the Program Resident: * Required.
Comments (if any):
Contact Information
Name of person completing this form:	* Name is required.
Email:	* Email is required.
Telephone number:	* Phone number is required.

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 Email: Annamarie.Grady@Pennmedicine.upenn.edu