Research Associate Application Dear Practitioner:

KALEIDA HEALTH Research Associate Application Dear Practitioner: Enclosed is an application for status as a Research Associate and the appropriate job description. Please return the completed application and supporting documents to: Kaleida Health Office of Research and Sponsored Projects 726 Exchange Street, Suite 270 Buffalo, NY 14210 Attn: Kelly Gleason The following information/materials must be included with the completed application as applicable. We recommend you use this as a check sheet to assure compliance. Copy of current Curriculum Vitae/Resume (Must contain month, day, year) Must provide an email address. Two (2) References - Please obtain two Reference Letters and submit with completed application. Reference letters cannot be more than six months old. Description of any malpractice or professional misconduct actions or proceedings (Section IX.2.) Signed General Indemnification Form ("Certifications, Authorizations and Waivers of Liability") Complete current Medical Evaluation Form, including vaccination records (Note: TB (PPD) tests and flu shots are required annually) Completed and signed RN job description (if applicable) Completed Criminal Record Check Consent Form and National Student Clearinghouse Consent Form Completed Scope of Service (signed by your Supervisor) Signed copy of your current NYS License Registration Certificate Copy of your College Diploma and/or Training Certificates Copy of your ECFMG certificate (if applicable) Copy of VISA (if applicable) Copy of your insurance certificate (if you will not be employed by Kaleida Health) Two (2) Passport Quality Photos and a Valid Photo ID (Driver s License or Copy of Passport) Check for processing fee of $50.00 made out to Kaleida Health PLEASE NOTE: We cannot process an application without the Passport Photos & Valid Photo ID. Thank you for your anticipated cooperation. Be advised that upon receipt of all required information and documents, the average processing time is about two weeks. Therefore, it is important to return the completed application, along with the required attachments, as soon as possible. All information must be typed or printed. Your name must be on every page. If more space is needed, attach additional sheets and make reference to the questions being answered. If you have any questions or if you should need assistance, please call the Office of Research and Sponsored Projects at 859-8933. Sincerely, Victoria Belniak, Vice President Compliance, Internal Audit and Privacy

KALEIDA HEALTH RESEARCH ASSOCIATE APPLICATION IF THERE IS ANY ADDITIONAL INFORMATION THAT IS NOT ACCOMMODATED ON THIS FORM, PLEASE LIST ON SEPARATE PAPER Primary Clinical Affiliation Requested (Medicine, Surgery, etc.) I. IDENTIFYING INFORMATION Last Name First Name Middle Initial Degree(s) Sex F M Other Name under which information may be found Email address Birthplace Date of Birth Citizenship Social Security Number Primary Office Address - Mailing Address (Practice Name/Street#/City/State/Zip) Phone: _ Fax: Secondary Office Address - (Name of Practice/Street #/City/State/Zip) Phone: _ Fax: Home Address (Street #, City, State, Zip) Phone: _ Fax: Beeper Number Private Phone Number Answering Service II. LICENSES AND NUMBERS List all professional licenses, currently held. Attach copy of state registration(s) New York State License Number - Attach a copy of State registration Additional License Numbers: (State) License No. Exp. Date Active? Inactive? Terminated? ECFMG # (attach copy) III. New York State Professional Liability Insurance (attach facesheet): Additional Professional Liability Insurance: Name of Carrier Address of Carrier Policy # Effective Date Expiration Date Type of Coverage/Amt. Page 1

IV. PROFESSIONAL REFERENCES List (3) of the same title as yours (such as: MD/NP/PA/RN) Name Address (Street #, City, State, Country, Zip & e-mail addresses) Phone #: V. MEDICAL/DENTAL/NURSING SCHOOL. List school of graduation. If others, list separately. Attach copy of diploma. Name of School Date of Graduation Degree Honors School Address (Street #, City, State, Country, Zip) VI. OTHER TRAINING If others, list separately. Name of Institution Date of Graduation Degree Institution Address (Street #, City, State, Country, Zip) Infection Control Training - Attach certification of completion of an approved course within the past 36 months, if applicable. VII. INTERNSHIP/RESIDENCY List all internships and residencies in chronological order, most recent first. Name of Hospital/Health Care Facility Start Date End Date Completed? Specialty Y N Full Address (Street #, City, State, Country, Zip) Type Program Director Name of Hospital/Health Care Facility Start Date End Date Completed? Y N Specialty Full Address (Street #, City, State, Country, Zip) Type Program Director Name of Hospital/Health Care Facility Start Date End Date Completed? Y N Specialty Full Address (Street #, City, State, Country, Zip) Type Program Director VIII. FELLOWSHIPS. List all academic fellowships in chronologic order, most recent first. Name of Hospital/Health Care Facility Start Date End Date Completed? Y or N Full Address (Street #, City, State, Country, Zip) Program Director Name of Hospital/Health Care Facility Start Date End Date Completed? Y or N Full Address (Street #, City, State, Country, Zip) Program Director Name of Hospital/Health Care Facility Start Date End Date Completed? Y or N Full Address (Street #, City, State, Country, Zip) Program Director Specialty Specialty Specialty Page 2

IX. ANSWER ALL OF THE FOLLOWING: PLEASE NOTE: Please completely fill in the answer blocks for each question. Do not draw circles around your answers or use an arrow or line for selections. We will return applications that ignore this directive. 1. Have any of the following been denied, revoked, suspended, sanctioned, reduced, limited, monitored, placed on probation, not renewed, or voluntarily relinquished to avoid possible disciplinary action in any jurisdiction? Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Yes No h. Yes No i. Yes No j. medical, dental or other professional license controlled substance registration (DEA) academic appointment membership in or affiliation with any health care facility staff clinical privileges at any health care facility prerogatives or rights at any health care facility professional society membership or fellowship board certification professional liability insurance participation in any private, Federal or state insurance program (eg. Medicare, Medicaid) 2. To the best of your knowledge: Yes No a. Yes No b. Yes No c. Yes No d. Yes No e. Yes No f. Yes No g. Have you ever been charged with professional misconduct or received an administrative warning by any state agency or professional association? Are you the subject of any current investigation by any state agency or professional body? Have any misdemeanor or felony charges been brought against you? Have there ever been any findings or have you ever been found to be in violation of Patient Rights? Have any judgments or settlements been rendered against you in a professional liability case? Have you received notice of malpractice actions which are pending? Do you have any physical or mental disorders which may interfere with the practice of your discipline/specialty including alcohol or drug dependence? 3. If the answer is YES to any of the above questions, please explain on a separate sheet. I understand that it is my responsibility to advise Kaleida Health in writing immediately of any new, different, or additional information responsive to any of the above questions. XIII. MEDICAL HISTORY AND PHYSICAL EXAMINATION ~ Annual Medical Evaluation ATTACH COPY Page 3

CERTIFICATIONS, AUTHORIZATIONS AND WAIVERS OF LIABILITY I fully understand that any misstatements in, or omissions from, this application or the supporting documentation submitted herewith, constitutes cause for denial of my request or cause for summary dismissal. All information submitted by me in connection with this application is true and complete to the best of my knowledge and belief and no pertinent information has been omitted. In making this application, I acknowledge that I am familiar with the principles and standards of the Det Norske Veritas (DNV), the Guidelines for Good Clinical Practice, and Ethical Principles and Guidelines for the Protection of Human Subjects of Research contained in the Belmont Report and the Declaration of Helsinki. I agree to be bound by the principles thereof, and I further agree to abide by such Hospital(s) policies as may be from time to time amended and enacted. I hereby signify my willingness to appear for a personal interview in regard to my application, authorize the Hospital(s) representatives to consult with administrators and members of other hospitals or institutions with which I may have been associated and with others, including past and present malpractice insurance carriers, who may have information bearing on my professional competence, character and ethical qualifications. I hereby further consent to the inspection by Kaleida Health and its representatives of all records and documents, including medical records from other hospitals that may be made material to an evaluation of my professional qualifications and competence to carry out the privileges requested as well as my moral and ethical qualifications for the position as Research Associate. I hereby release from liability Kaleida Health and its representatives for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications. I hereby release from any liability, any and all individuals and organizations who provide information to Kaleida Health in good faith and without malice concerning my professional competence, ethics, character and other qualifications and I hereby consent to the release of such information. I authorize Kaleida Health to conduct a criminal record background check for the purpose of determining my suitability for privileges as a Research Associate at Kaleida Health. I understand that if it is discovered that I have a criminal record, Kaleida Health may deny my application for Research Associate privileges. I authorize Kaleida Health to share the information I provide in this application for Research Associate privileges to Erie County Medical Center Corporation in order to expedite its research associate application process, if applicable. I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any questions or doubts about such qualifications. I have been advised of, and hereby acknowledge, my obligation to advise Kaleida Health in writing immediately of any new, different or additional information responsive to any of the questions or items requested in or in connection with this application which, at anytime it comes to my attention or is made known to me. DATE SIGNATURE OF APPLICANT

KALEIDA HEALTH Medical Evaluation Form KALEIDA HEALTH Erie County Medical Center Roswell Park Cancer Institute Please check your primary affiliation: Mercy Hospital of Buffalo Kenmore Mercy Sisters of Charity Hospital In keeping with the requirements of the New York State Department of Health, I certify by my signature below that I have performed a medical evaluation on: Dr./Mr./Ms.: Please Print Name Section A: PAST HISTORY MEDICAL: SURGICAL: FAMILY HISTORY: REVIEW OF SYSTEMS: ALLERGIES: MEDICATIONS: HABITS: Section B: As required, the following information is provided: 1. Immunity to Rubella: Rubella Antibody Test Date: Result: _ If negative, date of Immunization: // 2. Immunity to Measles has been documented as follows: (Please check) _ Rubeola Date of Titer: _ Result: Vaccination with Live Measles Vaccine Date Immunized: MMR Date Immunized: (CONTINUED see next page)

MEDICAL EVALUATION FORM - Page 2 3. Tuberculin Skin Test (PPD): Date Performed: / / Results (please check): _ Positive/Active TB Ruled Out by Chest X-Ray _ Chest X-Ray Date: _ Result: Negative/MUST BE REPEATED ANNUALLY IF PPD NOT PERFORMED, PLEASE INDICATE THE REASON BY CHECKING ONE OF THE FOLLOWING: _ Significant prior reaction/no clinical signs/symptoms suggestive of active TB _ Adequate treatment of known prior disease, egs. BCG/No clinical signs/symptoms suggestive of active TB _ Completion of Adequate Preventive Drug Therapy, egs. INH/No clinical signs/symptoms suggestive of active TB _ Pregnancy/No clinical signs/symptoms suggestive of active TB 4. Flu Shot (Influenza): Date Performed: / / Declined (reason): (If flu shot declined, you are required to wear a mask at all times if you are on site or have patient contact.) 5. Optional Hepatitis B Date: Pneumonia Date: DT Date: Other (please specify): Dates: Section C: PHYSICAL EXAMINATION BP: _ TEMP: _ PULSE: _ RESP: _ WEIGHT: _ EYES: ENT: NECK: LUNGS: HEART: BREASTS: ABDOMEN: RECTAL: PELVIC: EXTREMITIES: NEUROLOGIC: Please Note: Kaleida Health does not allow a practitioner to attest to his/her own health status. If you submit the Catholic Health H & P form, another physician must attest to your health status. I have determined that the above-named practitioner is free from any health impairment which is of potential risk to patients or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior. SIGNATURE OF EXAMINING PRACTITIONER _/_/_ DATE TYPED OR PRINTED NAME

Kaleida Health Research Associate Applicant Criminal Record History Have you ever been convicted of a felony? _ yes _ no If yes, please explain: Criminal Record Check Consent Form I authorize Kaleida Health to conduct a criminal record background check for the purpose of determining my suitability for privileges as a Research Associate at Kaleida Health. Name: Last/ First/ Middle Maiden Name/Names Previously Used: Birth date: Sex: M F Social Security Number: I authorize Kaleida Health to utilize the above information for the purpose of obtaining a criminal background check. I understand that if it is discovered that I have a criminal record, Kaleida Health may deny my application for Research Associate privileges. Applicant s Signature Print name Date

Kaleida Health Research Associate Applicant National Student Clearinghouse Consent I authorize Kaleida Health to conduct a verification of my degree/diploma for the purpose of determining my suitability for privileges as a Research Associate at Kaleida Health. Name: Last/ First/ Middle Maiden Name/Names Previously Used: Birth date: Sex: M F Social Security Number: School Attended: Date of Graduation: Degree Title: I authorize Kaleida Health to utilize the above information for the purpose of verifying my degree/diploma. I understand that if it is discovered that I have not provided accurate information and my degree/diploma cannot be verified, Kaleida Health may deny my application for Research Associate privileges. Applicant s Signature Print name Date

Service Applicant s Name (Print) Print Supervisor Name Affiliated Entity Print Chief of Service Name (Must be a member of the Kaleida Health Medical Dental Staff) SCOPE OF PRACTICE RESEARCH ASSOCIATE Research pursuant to IRB approval. Attach IRB approval. If consent is required, consent forms will be obtained from each patient and copies will be maintained. Research will involve only de-identified patient information. Requests to be made for data to Kaleida Health Decision Support. Research will require access to individual's PHI. Consent forms will be obtained from each patient and copies will be maintained. Age Range of Patient Population: (Please check) Pediatric Adult Geriatric PART I: PART II: DEFINITION - A Research Associate MAY NOT PROVIDE PATIENT CARE. A Research Associate s tasks, including those involving patient contact and/or patient-related activities, are limited to those specifically defined and approved within this Scope of Practice. SUPERVISORY REQUIREMENTS - All Research Associates must be supervised by a member of the Kaleida Health Medical Dental Staff. PART III: COMPETENCIES - 1) Core Competencies - a) Bench Research/Laboratory Setting b) Collect, Collate & Maintain Data 2) Patient Interaction: (List any activities not listed under the Core Competencies in #1) Criteria: Research Associate s Supervisor must complete Part IV confirming that he/she can personally attest to the applicant s competence with regard to the activities listed below. Following submission and review of this request, additional documentation may be required. PART IV: ACCESS REQUIRED - List all Kaleida Health systems/applications required for research: Approved by Supervisor _ (Supervisor Initials) 1 ST COLUMN TO BE COMPLETED BY APPLICANT MUST BE INITIALED BY CHIEF OF SERV. Requesting approval for the above named Research Associate to participate in the following patient contact and/or patient-related activities. Approved *Not Approved With Direct Supervision PART V: SUPERVISOR S ATTESTATION: As this Research Associate s supervisor, I personally attest to the competence of the above applicant with regard to the activities listed in Part III, above. _ Signature, Supervisor _ Signature, Vice President Compliance, Victoria Belniak Internal Audit and Privacy Date _/_/_ Date _/_/_