Graduate medical education employment application form



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GRADUATE MEDICAL EDUCATION EMPLOYMENT APPLICATION FORM
Please Print/Type
Program Name Completing Application for:

     

Training to Begin On:

     


Name:

     


Contact Address:

     

Permanent Address:

     




Home Phone Number:

     

Work Phone Number:

     

Cell Phone Number:

     

Fax Number:

     

Email:

     

National Provider Identifier Number:

     

Gender:

     

Birth Date: (mm/dd/yyyy)

     

Birth Place:

     

Citizenship Country:

     

Visa Type (if applicable):

     


Examinations

Examination

Status (Passed/Failed)

3- Digit Score

Date

USMLE Step 1

     

     

     

USMLE Step 2 CK (clinical knowledge)

     

     

     

USMLE Step 2 (clinical skills)

     

     

     

USMLE Step 3

     

     

     


Medical Licensure

Board Certification? (yes/no)

     

If yes, which Board:

     

Ever Named in a Malpractice Suit? (yes/no)

     

State Medical License? (yes/no)

     

If yes, which state, number, expiration date:

     


Educational Commission for Foreign Medical Graduates Certification

Are you certified by the ECFMG? (yes/no)

     

If yes, ECFMG Number:

     


Medical Education

Institution & Location

Dates Attended

Degree

Date of Degree (mm/dd/yyyy)

     

     

     

     

Medical Education/Training Extended or Interrupted? (yes/no)

     

If yes, the reason:

     


Medical Education Honors/Awards

     


Education (list all graduate and undergraduate schools)

Education
(not medical)

Institution & Location

Dates Attended

Degree

Degree Date (mm/dd/yyyy)

Field of Study

Graduate

     

     

     

     

     

Undergraduate

     

     

     

     

     


Current/Prior Medical Training

Experience/Specialty

Institution & Location

Program Director

Dates Attended (mm/dd/yyyy)

Years of Training

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


Hospital and Clinical Work Experience

Position

Hospital/Practice Name

City/State/Zip

Dates

From mm/dd/yyyy To mm/dd/yyyy



     

     

     

      to      

     

     

     

      to      

     

     

     

      to      


Publications

     


Language Fluency (other than English)

     


Hobbies & Interests

     


Other Awards/Accomplishments

     



Have you ever been
Convicted of any offense other than a minor traffic violation, misdemeanor or crime?  YES  NO

If yes, explain all convictions:



     

Ever been reported to the National Practitioner Data Bank, Healthcare  YES  NO

Integrity and/or Protection Data Bank?
Has your employment, medical staff appointment, panel participation, affiliation  YES  NO

or clinical privileges ever been voluntarily or involuntarily suspended, diminished,

revoked, refused or limited in any hospital, health care facility or managed care

organization, IPA or PPO including to avoid disciplinary action for reasons related to

professional competence or conduct?
Has your license to practice your profession in any jurisdiction every been limited,  YES  NO

restricted, suspended, revoked, denied or subject to probationary conditions?


Ever voluntarily or involuntarily relinquished your license to practice  YES  NO

your profession in any state?


Ever been suspended, sanctioned or otherwise restricted from participating  YES  NO

in any private, federal or state health insurance program (including Medicare,

Medicaid or a managed care organization)?
Has your narcotics registration certificate ever been voluntarily or involuntarily  YES  NO

limited, restricted, denied renewal, suspended or revoked?


Ever been denied membership, membership renewal or been subject  YES  NO

to any professional review, censure or reprimand in any medical organization

or professional society – local, state or national?
Ever been subject to disciplinary action by a state agency or  YES  NO

professional body (i.e., Medical Society, IPRO, OPMC)?


Has your specialty board certification or qualification ever been voluntarily or  YES  NO

Involuntarily denied, revoked, relinquished, not renewed, suspended or reduced?


Any pending misconduct charges against you in this state or any other state?  YES  NO
Presently subject to any suspension, revocation, discontinuance,  YES  NO

limitation, restriction or monitoring proceedings?


Ever been cited for violation of patient rights as set forth by the  YES  NO

Federal Law and/or NYS Department of Health or any other state department of health?


Assessed a penalty for violations in connection with Medicare or other federal/state

health care programs?  YES  NO


Entered into a settlement agreement relating to an alleged violation(s) in connection

with Medicare or other federal/state health care programs?  YES  NO


Debarred or suspended from participation in federal contracts or programs?  YES  NO
Subject to a debarment, suspension or exclusion proceedings?  YES  NO
The subject of a remedial or academic probation?  YES  NO
If yes to any of the above questions, please explain:

     

If employment is offered, you will be required to produce documents establishing identify and authorization to work in the U.S.; pursuant to the Immigration and Control Act of 1986.


The University is an equal opportunity employer. The University does not discriminate on the basis of race, creed, color, religion, national origin, citizenship, age, sex, sexual orientation, disability, marital status, veteran status, or any other status protected by law.
This application may be available for review by all divisions of the University of Rochester and will become a permanent record for those employed. Therefore, all questions must be answered in their entirety where applicable.
I hereby certify that the information herein is correct, and I understand that any misrepresentation, including omission of information, when discovered, will result in termination. I also understand that I may be required to complete a post-offer health assessment that may include a drug test. I am also aware that a criminal background check may be performed. In addition, I authorize release of reference information by all past, present employers and educational institutions as well as references provided by me.
I understand that this application is neither a contract of employment nor an offer of a contract of employment, express or implied, between me and the University of Rochester. I further understand that if I should become employed by the University of Rochester, my employment shall be at will, which means that it may be terminated by me or by the organization at any time, for any reason, or no reason, with or without notice.



DATE:




APPLICANT SIGNATURE







APPLICANT PRINTED NAME:







  1. Mail completed and signed application with a personal statement including comments on the selection of Radiology as a career.

  2. Three letters of recommendation from faculty, a Dean’s letter from your medical school, and a complete transcript from your medical school is required and should be included with your application packet.

  3. FOREIGN MEDICAL GRADUATES: Please include a copy of your valid ECFMG certificate. ECFMG certification is REQUIRED of all foreign medical graduates.

  4. Address ALL material to:

Julie Bissonnette, Program Coordinator




     

(Insert Fellowship Type)

University of Rochester Medical Center

Department of Imaging Sciences, Box 648

601 Elmwood Avenue

Rochester NY 14642-8648




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