Section I: To be completed by the Visiting Resident Last Name First Name Middle Initial Email address *NOTE: Must be a professional (university/institution) address, personal email (gmail, yahoo, etc.) not accepted. Contact Phone Number Mobile Home Will you require use of a local pager in Grand Rapids? Yes No If no, provide pager number to be used while rotating in Grand Rapids Current Residency Program Current PG Year Program Address Program Director or Coordinator Phone Residency Program Institutional Sponsor ROTATION REQUEST(s) s 1st Choice 2nd Choice 3rd Choice TO TO TO Approved Office Use Only Coming Type of Learner Application Processed
BACKGROUND INVESTIGATION RELEASE STATEMENT Print Full Name Other Names Used of Birth * Social Security Number Driver s License Number NPI Number State/Country Individual DEA Number (*If permanent physician license holder) Home Address History: Current home address first Include city, county, state, zip, country, and dates at each address (Must have at least prior 10 years of home address): Address, City, County, State, Zip, Country s at address (List current address first) 1. 2. 3. 4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Employment History/Information 1. Name of employer 2. Name of employer 3. Name of employer 4. Name of employer 5. Name of employer
6. Name of employer 7. Name of employer 8. Name of employer 9. Name of employer 10. Name of employer
* of Birth to be used exclusively for record checking purposes and will not be used for any other purposes. Prior to your Visiting Learner Rotation and as part of the Visiting Learner Application process with Grand Rapids Medical Education Partners, I understand that investigative background inquiries are going to be made on me. I understand that you will be requesting information from various Federal, State, Local and other agencies which maintain records concerning my past activities relating to my driving history, credit, criminal, civil and other experiences. These reports may also include inquiries regarding my educational history and past work experience and performance including reasons for termination of employment. I authorize, without reservation, any party or agency contacted by this employer or its agents to furnish any of the above mentioned information or any other information requested. I understand that such information may contain my social security number. I release all parties from all liability for any damage that may result from furnishing that information to this company. I understand that the information generated, received or maintained during and as a result of this investigation will be maintained as confidential information. A photocopy of this document is considered to be as valid as the original document. I acknowledge that I have received a copy of my rights under the Fair Credit Reporting Act. Signature: Must be hand signed. Typed electronic signatures cannot be accepted. : Email Address: Phone Number:
I authorize my home Program Director, to release to Grand Rapids Medical Education Partners, all performance and health information necessary to complete SECTION II of this application. Applicant s Signature SECTION II - TO BE COMPLETED BY RESIDENT S PROGRAM DIRECTOR Please provide the following information regarding Printed Resident s Name YES NO The above-named Resident is currently in good standing. YES NO The above named Resident has the required academic background and skills necessary to participate in and is approved to take the requested rotation. If there have been any academic/clinical performance, liability, disciplinary, or other problems with this Resident, please explain: The above-named resident completed Blood Borne Pathogen Training on, Universal Precautions Training on and HIPAA training on. agrees to incur the cost of the above-named Resident s Name of Resident s Program salary and benefits during his/her rotation(s) at Grand Rapids Medical Education Partners. agrees to provide professional liability coverage for the Name of Resident s Program above-named Resident during his/her rotation at Grand Rapids Medical Education Partners. (GRMEP does not provide liability coverage for visiting Residents) Proof of Professional Liability Insurance must be attached to this application I agree to all of the preceding terms and affirm that all submitted information is correct: Program Director s Signature Printed Name
Visiting Learner Non-Refundable Application Fee $500.00 (1 st rotation per academic year) $250.00 (each rotation after) ***Application fee subject to change*** Resident VL 5590-199 Learner Name: Requested Rotation: s of Rotation: Credit Card Number: CVV or Security Number: Credit Card Expiration: Learner Signature: Mail to: Sidra Tees GME Scheduling Department Grand Rapids Medical Education Partners 945 Ottawa Ave NW Grand Rapids, MI 49503 Fax to: 616.233.6635 Confidentially email to: schedulemanager@grmep.com *NOTE: Credit cards (Visa, MC), money orders, cashier s checks, or business checks from the sponsoring institution will be accepted. **No Discover or AMEX cards, personal checks, or cash.
Visiting Resident Application Checklist I understand submission of an application does not constitute approval of rotation request. I have attached copies of all required documentation, including but not limited to: Current Educational Limited or Permanent Medical and Controlled Substance License ERAS Application ECFMG Certificate (if international medical school graduate) Medical School Diploma Certificate of Professional Liability Insurance which will provide coverage while rotating with Grand Rapids Medical Education Partners (GRMEP does not provide liability coverage for visiting residents) Proof of Blood Borne Pathogen, Universal Precautions, and HIPAA Training BLS and ACLS Certificates NRP and/or PALS Certificates (if requesting inpatient pediatric rotation) ATLS Certificate (if requesting trauma rotation) Rotational Goals and Objectives I have attached documentation confirming my immunization history including but not limited to Whooping Cough (DPT or TDaP), MMR, Rubella, Rubeola, Varicella, Hepatitis B, Flu, and TB. I hereby release Spectrum Health Occupational Medicine, Grand Rapids Medical Education Partners and Mercy Health Saint Mary s Employee Health Office and its employees, staff and agents from all legal responsibility or liability that may arise from the disclosure of the information set forth relating to my file. I have completed the background investigation release statement (above) and understand my rights under the Fair Credit Reporting Act. I have attached the credit card form for my non-refundable application fee (OR) My program/institution will pay my application fee(s) ($500 for the first rotation of the academic year and $250 for each subsequent rotation) If accepted for a rotation at GRMEP, the Resident agrees to the following: Resident will comply with all GRMEP and specific training site policies. Resident will perform assigned duties to the best of his/her ability. Resident will provide his/her own housing. Resident will complete any required orientations. Resident will maintain patient confidentiality by following all HIPAA regulations. Submit completed application via mail to: Sidra Tees, 945 Ottawa Ave NW, Grand Rapids, MI 49503. Email to schedulemanager@grmep.com or fax to 616-233-6635. Applicant s Signature Printed Name