Forms

Affiliation Agreements

ACGME Resident/Fellow Survey (example)

ACGME Resident/Fellow Survey Educational Tool (Example)

Contract (Resident/Fellow)

Evaluation Forms (360; semi-annual, faculty, program, resident/fellow)

Elective Form:  This form must be completed by the resident/fellow, approved and signed by the program director, and faxed to the UMMC GME office at 410-328-2088 for review and approval by the DIO and MMCIP (self-insurance trust) before the elective activity is permitted.  90 days advance notice is required.

I-9 Employment Eligibility and Verification  Residents/Fellows must complete this form and bring ORIGINAL  documents AND  LEGIBLE PHOTOCOPIES of your Identification and Eligibility for Employment documents in order to be added to the Medical Center's payroll.

Licensing Registration Forms: This form is required to register all unlicensed residents/fellows as Unlicensed Medical Practitioners (UMP)

Moonlighting/Extra Sessions Form: This form required to be completed by the resident/fellow, signed by the program director, medical staff services and the self-insurance trust (MMCIP) before the extra session or moonlighting activity can be considered for approval.

New Hire Form New residents and fellows will also be asked to provide a completed New Hire Form order to satisfy the the requirements to be added to payroll.

Offer Letter Residents/Fellows: A standardized offer letter is required for all applicants that will be enrolled in post-graduate clinical training programs sponsored by the University of Maryland Medical Center. This form is also available through the Graduate Medical Education website at Residency Coordinators > Policies, Procedures and Forms > Other Policies, Procedures and Forms

Resident /Fellow Data File:  This file is to be completed by the Program Liaison (e.g., Residency Coordinator, Administrative Assistant, Program Director) to assure that all residents and fellows are appropriately credentialed. The  instructions for completing, along with the form are identified with this form and which are also available on the Graduate Medical Education website at Residency Coordinator > Postmatch Processes > Paperwork Processes > Credentialing, Contracting, Licensing Timelines

Rotator Agreements:  A variety of rotator agreement formats and instructions for choosing the format can be found at
Residency Coordinator
> Policies Procedures and Forms > Affiliation and Rotator Agreements (includes Timelines, Protocol and Templates)

Tax Forms - Maryland -  New residents and fellows will also be asked to provide a completed state tax form order to satisfy the the requirements to be added to payroll.

Tax Forms - Federal New residents and fellows will also be asked to provide a completed federal tax form order to satisfy the the requirements to be added to payroll.

Unlicensed Medical Practitioner Registration Form: This form is required to register all unlicensed residents/fellows as Unlicensed Medical Practitioners (UMP) Note this is the same form that appears under the heading Licensing Registration Forms on this page.

This page was last updated: July 16, 2013

         
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