Visiting Resident/Fellow PLA Request Form

Visiting Resident/Fellow PLA Request Form

Thank you for your interest in coming to Guthrie! By completing this form, you will initiate a formal request for an affiliation agreement and Program Letter of Agreement (PLA). Please provide the information requested. If you have any questions or need support completing this form, please contact Valerie Short, GME Institutional Coordinator, at (570) 887-4537 or by emailing her at Valerie.Short@guthrie.org.

It is recommended that you review the form before completing because submission without required information will not be accepted.

DATE OF REQUEST:*

Requestor's First Name:*

Requestor's Last Name:*

REQUESTING PERSON'S EMAIL ADDRESS:*

Requestor's Phone Number:*

Name of Requesting Affiliate*

Please provide the legal name of the institution/program making this request.

Type of Trainee*

Please use the drop-down menu to indicate if this agreement is for residents or fellows.

Select

GUTHRIE PROGRAM TO HOST TRAINEE*

Please identify the Guthrie program that will host your trainee.

Select or enter value

Current Program Coordinator's Name:*

Current Program Director's Name:*

Resident/Fellow's Current Program Director's Email Address*

Please provide the requesting resident/fellow's current program director's email address.

Requested Start Date:*

Please note that the request must be at least 60 days in advance of the submission/request date. If there isn't currently an affiliation/Program Letter of Agreement the future request date must be 120 days in advance of the target start date.

Requested End Date:

NAME/TITLE of GME Person Responsible for Affiliation/PLA Agreements.*

Please identify the name of the GME Office contact responsible for affiliation and Program Letters of Agreement.

Email Address for GME person responsible for affiliation and Program Letters of Agreement.*

Phone Number of GME Person Responsible for Affiliation/PLA Agreements.*

Phone

Duration of PLA*

Please identify the date range for the requested PLA. Please note that Guthrie has a five year maximum for all agreements.

PGY-LEVEL ATTENDING ROTATION*

Please use the drop-down menu to identify the training year of the resident/fellow requesting this rotation.

Select

PLA Focus*

Please identify the specialty areas focus for the requested PLA and any additional information about the rotation.

Name of Rotation*

Please provide a name for this rotation.

DURATION OF ROTATION:*

Select

Number of Resident Rotating Annually?*

How many residents/fellows are requested to rotate annually as a result of this agreement?

File Upload:*

Please upload a copy of the proposed goals and objectives for the rotation.

Drag and drop files here or

Send me a copy of my responses

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