APPLICATION FOR REAPPOINTMENT RESEARCH ASSOCIATE

APPLICATION FOR REAPPOINTMENT RESEARCH ASSOCIATE Enclosed is an application for reappointment to the position of Research Associate. We ask that you review the shaded areas to assure that all current information is correct and indicate changes where applicable. You must respond to all questions. Your application will be considered incomplete if you fail to respond to any questions. If a question does not apply to you, please respond by stating not applicable. The following information/materials must be included with the completed application. We recommend you use this as a check sheet to assure compliance. Two (2) References. Please obtain two reference letters and submit with completed application. Reference letters cannot be more than six months old. A copy of the face sheet of your current malpractice or professional liability insurance (must include effective dates of policy), if applicable. Description of any malpractice or professional misconduct actions or proceedings since your last appointment, if applicable. Completed and signed Scope of Practice Form. Signed copy of your current NYS License Registration Certification. Copy of current Infection Control Certificate, if applicable. Current completed Health Assessment Form with a PPD test and flu shot completed within the previous 12 months. Copy of current Collaborative Agreement. Nurse Practitioners/Nurse Midwives only. (Must list current NYS approved Practice Protocols.) Physician Assistant Certification - NCCPA. (PAs only) Copy of a Valid Photo ID (Examples: Driver s License, Non-Driver s License, US Dept. of State Passport) Check for $50.00 made payable to "Kaleida Health". PLEASE NOTE: Your scope of practice must fall within the scope of privileges held by your Supervising/collaborating physician. Any questions should be directed to the Office of Research and Sponsored Projects (859-8933). YOU MUST RETURN ALL DOCUMENTS WITHIN THREE WEEKS OF RECEIPT TO: #Name_LFM_T# Kaleida Health, Office of Research & Sponsored Projects 726 Exchange Street, Suite 270, Buffalo, NY 14210, Attn: Kelly Gleason

KALEIDA HEALTH Research Associate - Reappointment Application If you do not wish to reapply to Kaleida Health, please check the statement below, sign where indicated, and return this packet to the Kaleida Health Office of Research & Sponsored Projects, Kaleida Health, 726 Exchange Street, Suite 270, Buffalo, NY 14210. _ I wish to withdraw from Kaleida Health effective (date) IF THERE IS ANY ADDITIONAL INFORMATION THAT IS NOT ACCOMMODATED ON THIS FORM, PLEASE LIST ON SEPARATE PAPER I. IDENTIFYING INFORMATION Last Name First Name Middle Initial Degree(s) Sex Other Name under which information may be found Marital Status Name of Spouse Birthplace Date of Birth Citizenship Social Security Number Primary Office Address - Mailing Address (Street/City/State/Zip) Phone: Fax: Secondary Office Address - (Street /City/State/Zip) Phone: Fax: Home Address (Street, City, State, Zip) Phone: Fax: Beeper Number Private Phone Number Answering Service II. AFFILIATIONS List all present and previous affiliations in chronological order, most recent first. Please designate the facility (one) which you consider your Primary Hospital. Hospital/Healthcare Address Nature of Cl. Specialty/ Dates Affiliation Primary Affiliation/Position Subspecialty (From-To) III. 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 Exp. Dt Additional License Numbers: (State) License No. Exp. Date Active? Inactive? Terminated? DEA Number (attach copy) DEA Exp. Date UPIN ECFMG (attach copy) No. of CME Credits (attach copy)

#Name_LFM_T# - #F_ReApptDt# V. PROFESSIONAL LIABILITY INSURANCE List all current/previous (also excess liability) carriers. Attach copy(ies). New York State Professional Liability Insurance (attach face sheet): Additional Professional Liability Insurance: Name of Carrier Address of Carrier Policy No. Effective Date Expiration Date Type of Coverage/Amt. VI. MEDICAL/DENTAL REFERENCES List two (2) Professional s within your own specialty VII. CONTINUING EDUCATION Submit a list on separate sheet of all CME courses since last (re)appointment Please Provide Updated N.Y.S. Infection Control Training Course Certificate, if Applicable VIII. TEACHING APPOINTMENTS Name of Institution Start Date End Date Type of Appointment Institution Address (Street, City, State, Country, Zip) Department Chief Name of Institution Start Date End Date Type of Appointment Institution Address (Street, City, State, Country, Zip) Department Chief 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 selection. We will return applications that ignore this directive. 1. Since your last appointment, 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. medical, dental or other professional license Yes No b. controlled substance registration (DEA) Yes No c. academic appointment Yes No d. membership in or affiliation with any health care facility staff Yes No e. clinical privileges at any health care facility Yes No f. prerogatives or rights at any health care facility Yes No g. professional society membership or fellowship Yes No h. board certification Yes No i. professional liability insurance Yes No j. participation in any private, Federal or state insurance program (eg. Medicare, Medicaid) 2. Since your last appointment to the best of your knowledge: Yes No a. Have you ever been charged with professional misconduct or received an administrative warning by any state agency or professional association? Yes No b. Are you the subject of any current investigation by any state agency or professional body? Yes No c. Have any misdemeanor or felony charges been brought against you? Yes No d. Have there ever been any findings or have you ever been found to be in violation of Patient Rights? Yes No e. Have any judgments or settlements been rendered against you in a professional liability case? Yes No f. Have you received notice of malpractice actions which are pending? Yes No g. 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.

#Name_LFM_T# 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 the application or cause for summary dismissal as a Research Associate of Kaleida Health. 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. By submitting my application to Kaleida Health, I hereby signify my willingness to appear for a personal interview in regard to my application, authorize Kaleida Health and its 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 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 provide care within the scope of practice requested, as well as my moral and ethical qualifications. 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, including the Hospitals, their Medical/Dental Staffs and their representatives, who provide information to Kaleida Health or its Staff 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 understand and agree that I, as an applicant for Research Associate, 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, comes to my attention or is made known to me. _ DATE SIGNATURE OF APPLICANT

KALEIDA HEALTH ANNUAL HEALTH ASSESSMENT (Required by New York State) 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: (Name) As required, the following information is provided: 1. 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 Excluded from requirement/no clinical signs/symptoms suggestive of active TB (Please check reason): Significant prior reaction Adequate treatment of known prior disease Completion of Adequate Preventive Drug Therapy Pregnancy 2. 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.) 3. Optional Hepatitis B Date: Pneumonia Date: DT Date: Other (please specify) _ Dates: 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 OF EXAM TYPED OR PRINTED NAME Notice: 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. Return completed form to: Kaleida Health or Fax to: 859-8686 Office of Research & Sponsored Projects Attn: Kelly Gleason 726 Exchange Street Suite 270 Buffalo, NY 14210

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

Service Applicant s Name (Print) SCOPE OF PRACTICE RESEARCH ASSOCIATE Age Range of Patient Population: (Please check) Pediatric Adult Geriatric PART I: 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. PART II: 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. 1 ST COLUMN TO BE COMPLETED BY APPLICANT //COMPLETED 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 IV: 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, General Counsel Date / / Date / /