Check Out Form 2012 FINAL by k7ww9kn

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									        OFFICE OF GRADUATE MEDICAL EDUCATION RESIDENT CHECK OUT FORM 2012
This form must be completed by all residents terminating with The George Washington University Medical Center. Please
give us your name, present department/division, and your new location, position and forwarding address below. Have the
blanks below signed to indicate that you met clearance requirements for each item. Only signatures of those named below
are acceptable for each item.

             Department                        Time                                  Authorized Signatures

Medical Records – HOSP 1608           Monday through Friday     Mary Hopkins, Rachelle Norris, Ernestine Palmer, Clarissa
                                      8:00am to 4:00pm          McAbee, Janice Turner, Susan George
Touchworks – MFA system                                         Your residency program director or coordinator must verify that all
                                                                of your tasks have been completed in Touchworks.
Himmelfarb Library                    Monday through Friday     Kathy Lyons, Kathe Obrig, Alexandra Gomes, Catherine Harris,
                                      8:00am to 4:30pm          Elaine Sullo, J. Marie Miller, Anne Linton
Your Program (return your pager,
call room keys and any                                          Your residency program director or coordinator. This applies to
departmental/university property to                             residents and fellows in all departments.
your program coordinator)
Graduate Medical Education            Monday through Friday     Mary Tucker, Mary Mosby, Inga Ricks, Lisa Turner
Office: see list                      8:00am to 4:30pm          Note: No checkout during Orientation June 18, 19, 20 and July 2


Your residency certificate will be released when this completed form is presented to the GME Office, Ross Hall, Room 707.

Name: ___________________________________________                  Department : _____________________________________

New Position:__________________________________________________________________________________________

Forwarding Address:____________________________________________________________________________________

______________________________________________________________________________________________________

Email Address:__________________________________________________________________

NOTE: To have your W-2 forwarded to you at the end of the year, you must fill out the University’s “Inactive Employee
Change of Address Form.”

                                                  OBTAIN SIGNATURES BELOW:

Medical Records:___________________________________________                      Date:___________________________

Touchworks: ___________________________________________                          Date:____________________________

Library:___________________________________________________                      Date:___________________________

Program Signature:_______________________________________                        Date:____________________________


GRADUATE MEDICAL EDUCATION OFFICE:

             EXIT SURVEY COMPLETED:           YES ___________           NO __________

             Photo IDs: GME staff must sign to indicate receipt

                    Hospital ID___________       GWorld ID ___________       Date: ______________
               th
             6 Floor Keys (Fellows only) ______________                     Date: ______________

             Residency Certificate: Resident must sign to indicate receipt or request for mailing

                    Received from Dept._____________________________________

                    Received from GME:_____________________________________               Date: ________________

                    *Please mail to above address: _____________________________ Date mailed: ___________

         *Self-addressed mailing label completed by resident and attached to this form: ________

								
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