VISITING RESIDENT/FELLOW ROTATION REQUEST FORM AND APPLICATION

VISITING RESIDENT/FELLOW ROTATION REQUEST FORM AND APPLICATION

Thank you for your interest in rotating at Guthrie! Please review the request form/application prior to completing as required items are marked with an asterisk (*) and the form cannot be submitted without those information items.

All potential rotating residents/fellows should note that if a Program Letter of Agreement is not currently on file, it typically takes 90-120 days to process the agreement and no rotation can start until that document is fully executed.

You are encouraged to check the "cc" send me a copy of responses box at the end of the form so that you have a record of the request. Once submitted, the GME office will be notified of your request.

If you are having difficulty with this form, please email Valerie.Short@guthrie.org or Dale.Johnson@guthrie.org for assistance.

Date This Request is Submitted:*

Please enter today's date . You will be prompted to enter the requested rotation dates in fields later on in this application form. Please note, due to the time required to complete onboarding and credentialing (if rotating in NY), requests less than 60 days prior to the start of the requested rotation will be declined.

Requestor's Last Name:*

Please enter the requesting resident/fellow's last name.

Requestor's First Name:*

Please enter the requesting resident/fellow's first name.

Requesting Resident/Fellow Email Address:*

Please enter the requesting resident/fellow's email address.

Requestor's Phone Number:*

Please provide a phone or cell phone number than can be used to contact you directly.

Phone

Current Trainee Type:*

Select

VISA STATUS:*

Please use the drop-down menu to indicate if you currently hold a visa.

Select

PLA Focus*

Please identify the specialty that will be the focus of this rotation request.

REQUESTED SITE FOR ROTATION:*

Please use the drop-down menu to select the preferred site for your rotation.

Select

Does your program have a current affiliation/PLA with Guthrie?*

Please consult with your GME Office find out if a current affiliation agreement and Program Letter of Agreement (PLA) already exists. Please use the drop-down menu to indicate the status of an existing agreement. If there is no current agreement, then the rotation start date must be 90-120 days in advance of the request date.

Select

HOSTING PROGRAM:*

Please identify the Guthrie Training program that would assume supervisory responsibility for your rotation request.

Select

Guthrie Hosting Program Coordinator's Email Address:*

Please make sure you have contacted the hosting program's program coordinator. Please enter the hosting program coordinator's email address.

Guthrie Preceptor's Email Address:*

Please enter your Guthrie preceptor's email address:

Duration of PLA:*

Please use the drop down menu to indicate the length of duration for this PLA.

Select

Name of Rotation:*

Please provide the name of the rotation (i.e., Community Oncology, etc.)

TARGET START DATE FOR ROTATION*

PLEASE NOTE: If no prior affiliation agreement exists, the requested start date must be 90-120 days in advance of today's date. This is the standard amount of time it takes develop and execute this legal document.

Requested End Date:*

Current Residency/Fellowship Program Name:*

Please provide the name of the requesting resident/fellow's current training program (Sponsoring Institution).

Current ACGME Program Specialty*

PGY-LEVEL ATTENDING ROTATION*

Please identify your current training level using the drop down menu options.

Select

Current Program Coordinator's Name:*

Please provide your current program coordinator's name.

Current Program Coordinator's Email Address:*

Please provide the email address of your current program coordinator.

Current Program Phone Number:*

Please provide the phone number of your current program's contact person (generally program coordinator).

Current Program Director's Name:*

Please provide the name of your current program director.

Current Program Director's Email Address:*

Please provide the email address for your current program director.

GME Office Contact for Agreements/PLA*

Please provide the name of the GME person responsible for affiliation and PLA agreements.

Email Address of GME Affiliation Contact:*

Please provide the email address of the GME person responsible for affiliation and PLA agreements.

Name of Medical School:*

Please provide the name of your medical school.

Medical School START Date:*

Please enter the start date of medical school.

Medical School END Date:*

Please enter the END date of medical school.

Current PA Medical Training License?*

Please indicate if the resident/fellow currently holds a PA Training License.

Select

PA Medical Training License Number?

If the requesting resident/fellow has a PA Training License, please enter the license number.

PA Medical Training License Expiration Date:

If the requesting resident/fellow has a PA Training License, please enter the license expiration date.

Disabling Condition Requiring Accommodations?*

Please use the drop down menu choices to indicated if you have a disabling condition requiring reasonable accommodations during the requested rotation.

Select

Blood Borne & Airborne Pathogens Training?*

Please indicate the status of Blood Borne & Airborne Pathogen training.

Select

Documentation of Prior Hand-Hygiene Training?*

Guthrie requires that all incoming residents/fellows/students have documented hand-hygiene training. Please identify the status of your training using the drop-down menu choices provided.

Select

File Upload

Please upload a copy of your program approved goals and objectives for the requested rotation.

Drag and drop files here or

Send me a copy of my responses

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