ࡱ> npm ;bjbj x}c}c3$\Q)hv)x)x)x)x)x)x)$_+.)))U#U#U#:v)U#v)U#U#VR(@(0b7( b))0)(T.8.(.(p$U#6))"N). : Section 4 Assignment of Rotating Residents or FellowsDate Revised: January 2001, August 2001, September 2004, June 2006, July 2017, February 20204.2 Application for Residents Rotating from Other InstitutionsPage 1 of 5Application Procedure for Residents Rotating From Other Institutions For Electives at Saint Louis University School of Medicine Application procedures are as follows: SEQ 1,_2,_3, \* Arabic \r 11. A separate application must be completed for each elective rotation to which the resident is applying. SEQ 1,_2,_3, \* Arabic \n2. Each application must be complete including resident data, verifications and appropriate signatures before approval is given. Applications should be received at least 60 days prior to the anticipated rotation start date or training may be delayed. Out-of-state rotators may require longer processing times due to the need to obtain a Missouri physicians license. Additionally, during the high processing times for licensing in January and June, issuance of a Missouri physicians license could be significantly delayed. SEQ 1,_2,_3, \* Arabic \n3. The applicant completes Section I of the application and is responsible for having Sections II and III completed by the appropriate official of the institution in whose residency program the applicant is currently a member. SEQ 1,_2,_3, \* Arabic \n4. The applicant is to sign the Memorandum of Agreement (M.O.A.). SEQ 1,_2,_3, \* Arabic \n5. The applicant should return the application form of the Memorandum of Agreement along with copies of Missouri License, Missouri BNDD certificate, ECFMG Certificate, Federal DEA, Proof of Malpractice Insurance, and CV. The applicant must also show verification of the following: drug testing, criminal background check, HIPPA training, and health status. For rotations at Saint Louis University Hospital he/she must also complete SLUH orientation and IS security training. Upon receipt of the application and Memorandum of Agreement the Saint Louis University Program Director will complete Section IV of the application; obtain review and approval by the Department Chairperson of the M.O.A. and forward both the application and M.O.A., along withy all necessary documents to the Saint Louis University School of Medicine Office of Graduate Medical Education, Schwitalla Hall, M260, for M.O.A. final review, approval, and execution. A copy of all materials will be retained in the GME Office, and shared as necessary with affiliated institution officials. Originals of the completed application and the M.O.A. will then be forwarded to both the Saint Louis University Program Director and the rotating residents sponsoring institutions Program Director. Section 4 Assignment of Rotating Residents or FellowsDate Revised: January 2001, August 2001, September 2004, June 2006, July 2017, February 2020 4.2 Application for Residents Rotating from Other InstitutionsPage 2 of 5 Application For Residents Rotating From Other Institutions For Electives at Saint Louis University School of Medicine ____________________________________________________________ Directions: Please complete Section I; have Sections II and III completed by your sponsoring institution; and attach copies of your Missouri License, Missouri BNDD certificate and Federal DEA certificate. Return application to: Saint Louis University Program __________________________________ Saint Louis University Residency Program Director: Name: ______________________________________________________ Address: ____________________________________________________ ____________________________________________________ Phone: ______________________________________________________ ******************************************************************************** Section I To be completed by the applicant: Last Name: __________________ First Name: __________________ MI: ____ Degree: ____ Date of Birth: _________ MO License #: __________ BNDD #: _____________ DEA #: _________________ SS#: ___________________ ********************************************************************************************* Current Residency Institutional Sponsor: __________________________________________________________ Current Residency Program: _____________________________________ Start Date: _____________________ Phone #: _______________ Fax #: __________________ Pager #: _____________________ Saint Louis University Rotation: ________________________ Location: _____________________________ Rotation Start Date: ______________________ Rotation End Date: ___________________________ ********************************************************************************************* Prior US training-Complete the following: Prior Residency Program #1: _____________________________________________________________________ Location (city and state):___________________________________Start Date: _________ End Date: _________ Prior Residency Program #2: _____________________________________________________________________ Location (city and state):____________________________________Start Date: _________ End Date: _________ ********************************************************************************************* Medical School: ________________________________________ Graduation Date: _____________________ ECFMG Certification Number: __________________ ECFGM Certification Date: ____________________________ (a copy of the ECFMG Certificate must be attached) Residents Signature: _________________________________________________ Date: ___________________ Section 4 Assignment of Rotating Residents or FellowsDate Revised: January 2001, August 2001, September 2004, June 2006, July 2017, February 2020 4.2 Application for Residents Rotating from Other InstitutionsPage 3 of 5 Section II To be completed by the applicants current Residency Program Director: SEQ 1,_2,_3, \* Arabic \r 11. The resident named above is in good standing and currently a member of the _________________________ residency program. SEQ 1,_2,_3, \* Arabic \n2. On the dates requested for rotation, the resident is a PGY _____________ level resident. SEQ 1,_2,_3, \* Arabic \n3. An evaluation ____ will ____ will not be requested at the end of the elective rotation. SEQ 1,_2,_3, \* Arabic \n4. The resident has our approval to take this elective. _______________________________________________________________ Residency Program Director (Print) _______________________________________________________________ Residency Program Director (Signature) _______________________________________________________________ Name of Sponsoring Institution _______________________________________________________________ Date _______________________________________________________________________________ Section III To be completed by an official of the institution in whose program the resident is currently a member: SEQ 1,_2,_3, \* Arabic \r 11. Personal health coverage is in effect while the resident is away from our program SEQ 1,_2,_3, \* Arabic \n2. Malpractice insurance is extended to cover resident while the resident is on this elective rotation. (ATTACH PROOF OF MALPRACTICE INSURANCE.) SEQ 1,_2,_3, \* Arabic \n3. The resident has our approval to take this elective. ____________________________________ _______________________________________ Dean/President/CEO of Sponsoring Institution Name of Sponsor (Print) ____________________________________ _______________________________________ Dean/President/CEO of Sponsoring Institution Mailing Address (Signature) ________________________________________ _______________________________________ Title City, State, Zip Code ________________________________________ _______________________________________ Date Telephone Number ________________________________________________________________________________ Section IV: To be completed by Saint Louis University School of Medicine Residency Program Director: The resident ___ does have my approval to take the elective rotation indicated below: SLU Program: _____________________________________________________________________ Elective: _____________________________________________________________________ Dates of Rotation:_____________________________________________________________________ Program Director: ______________________________________________________________________ Name (printed) Program Director: _________________________________________________ _______________ Signature Date ________________________________________________________________________________ The form must be fully completed prior to approval by Associate Dean, School of Medicine. Section 4 Assignment of Rotating Residents or FellowsDate Revised: January 2001, August 2001, September 2004, June 2006, July 2017, February 2020 4.2 Application for Residents Rotating from Other InstitutionsPage 4 of 5 SAINT LOUIS UNIVERSITY AND AFFILIATED CLINICAL SITES CONFIDENTIALITY STATEMENT The undersigned hereby acknowledges his/her responsibility under applicable federal law and the rotational agreement between ______________________________________ (Sponsoring Institution and trainee) and Saint Louis University to keep confidential any information regarding Saint Louis University affiliated clinical sites (Sites) patients and proprietary information of these entities. The undersigned agrees, under penalty of law, not to reveal to any person or persons except authorized clinical staff and associated personnel any specific information regarding any patient and further agrees not to reveal to any third party any confidential information of Sites, except as required by law or as authorized by Sites. The undersigned agrees to comply with any patient information privacy policies and procedures of the University and Hospital. The undersigned further acknowledges that he or she has viewed a recording of the Sites patient information privacy practices in its entirety and has had an opportunity to ask questions regarding the Sites and Universitys privacy policies and procedures and privacy practices. Information Security Statement I understand that in the performance of my duties in affiliation with Saint Louis University and affiliate clinical sites (Sites), I am required to have access to and/or am involved in approved research necessitating access to patient care data. I acknowledge the patients right to confidentiality and will only access patient data to the extent necessary to perform my job responsibilities. I hereby agree to maintain the confidentiality of the patient care data at all times, both on premises and off. I further understand that any information relating to Saint Louis University and Sites is to remain confidential and may not be disclosed without appropriate administrative approval. I understand that a violation of patient confidentiality standards may result in disciplinary or a legal action against me. ________________________________ __________________ Signature date ________________________________ Printed Name Section 4 Assignment of Rotating Residents or FellowsDate Revised: January 2001, August 2001, September 2004, June 2006, July 2017, February 2020 4.2 Application for Residents Rotating from Other InstitutionsPage 5 of 5 SAINT LOUIS UNIVERSITY AND AFFILIATED CLINICAL SITES HEALTH AND BACKGROUND SCREENING ATTESTATION Health of Program Participants. Sponsoring Institution (or participant) , ________________________________, attests the Program Participant listed below has completed the following health screenings or documented health status as follows, and the trainee and institution will inform Saint Louis University with any changes with respect to the attestations. 1. Tuberculin skin test within the past 12 months or documentation as a previous positive reactor or a chest x-ray taken within the past 12 months; and 2. Proof of Rubella and Rubeola immunity by positive antibody titers or 2 doses of MMR; and 3. Varicella immunity, by positive history of chickenpox or proof of Varicella immunization; and 4. Proof of Hepatitis B immunization or completion of a certification of declination of vaccine, if patient contact is anticipated. 5. Negative drug screen. Background Checks. Sponsoring Institution has conducted a retrospective background check on all residents assigned to the program prior to their participation in clinical activities. Unless Saint Louis University Hospital is notified in writing, all background checks are negative. The background check included the following: Social Security number verification. Criminal Search (7 years ) Violent Sexual Offender & Predator registry HHS/OIG/GSA Participanting resident (Signature) _____________________________ Sponsoring Institution acknowledges this information will be available to Saint Louis University Hospital as reasonably necessary. 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