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.
APPLICANT PRINTED NAME:
Mail completed and signed application with a personal statement including comments on the selection of Radiology as a career.
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.
FOREIGN MEDICAL GRADUATES: Please include a copy of your valid ECFMG certificate. ECFMG certification is REQUIRED of all foreign medical graduates.