Jacksonville GME/UME Learning Intake Form

Jacksonville GME/UME Learning Intake Form

Thank you for taking the time to complete this form. Your responses will be used by Nemours Children’s Health to properly onboard you to our systems and credential you prior to your first day. The information provided will also be used for Medicare and Medicaid cost reporting purposes.

Last Name*

First Name*

Middle Initial

Have you had any prior rotations at Nemours?*

Yes

No

Gender*

Select

Race*

Select or enter value

Ethnicity*

Select

Date of Birth*

mm/dd/yyyy

Home Address*

Home Address 2

City, State, Zip*

Mobile Phone/Good contact number*

Phone

Email Address*

Emergency Contact Name*

Emergency Contact Number*

Phone

Learner Status*

Select

Preceptor at the Nemours site*

Rotation Start Date*

Rotation End Date*

Department You Will Be Rotating In*

Select

Rotation #2 start date

(if applicable)

Rotation #2 end date

(if applicable)

Department You Will Be Rotating In for Rotation #2

(if applicable)

Select or enter value

Rotation #3 start date

(if applicable)

Rotation #3 end date

(if applicable)

Department You Will Be Rotating In for Rotation #3

(if applicable)

Select

Anticipated Graduation Date*

Medical Education: Name of your medical/other school*

School Mailing Address

School Mailing Address 2

School City, State, Zip Code

Name of School Official or Contact*

School Official Email Address*

School Official Phone Number*

Phone

Sponsoring Institution Name*

(Name of Training Program)

Residency Program Specialty*

Residency Program Coordinator Name*

Residency Program Coordinator Phone Number*

Phone

Residency Program Coordinator Email*

Sponsoring Institution Mailing Address

Sponsoring Institution Mailing Address 2

Sponsoring Institution City, State, Zip

Current PGY Level*

NPI Number*

Medical License #*

Medical License Expiration Date*

Are you a foreign medical graduate?*

Yes

No

International Graduates, enter ECFMG # & attach copy of ECFMG certificate before submitting this form*

ECFMG Issue Date*

Degree*

For example: MD, DO, MBBS

Number of Weeks at Nemours

%

Is your program ACGME Accredited*

Yes

No

If no, enter program name*

Which Specialty are you considering for residency*

Pediatric Clerkship Grade in MS3*

Are you a member of AOA?*

Yes

No

Were you selected for the Gold Humanism Honor Society?

Yes

No

List the top 3 rotations you would be interested in taking this year at Nemours in order of preference*

List all dates that you are interested in rotating with Nemours in order of preference*

Do you self-identify as belonging to a group that is underrepresented in the medical profession relative to their numbers in the general population?

Yes

No

If yes, would you like us to email you additional information about the Nemours URiM Visiting Scholars Program by which you may be entitled to additional financial and educational perks while you complete your rotation with us?

Yes

No

File Upload

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Notes/Comments

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