GRADUATE MEDICAL EDUCATION by HC1210032080

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									                         NORTHWESTERN McGAW CENTER FOR
                           GRADUATE MEDICAL EDUCATION

                                  SIGN-OUT SHEET FOR 2011

All portions of this sign-out sheet must be completed by housestaff prior to their last day of training.
Certificates of completion will not be issued until the Office of Graduate Medical Education (420 E.
                                        th
Superior Street Rubloff Building, 12 Floor, 503-7975) has received this form with appropriate
signatures attached.


PLEASE PRINT CLEARLY

Name:                                           Program______________________________________

Forwarding
Address:_____________________________________________________________________________
                          (STREET)               (CITY)        (STATE)         (ZIP)

Email:                       Phone: __________________ Cell: ______________________

Career Path: (Please check the following)

___Academic Medicine        ___Private Practice    ___Research      ___Fellowship     ___Illinois


Signature_____________________________________________                          Date_______________




Departmental Clearance                  ________________________________________________
                                        (Program Administrator/Department)       (Date)



It is the responsibility of the training program to verify proper sign out for the items below :

         o      Medical Records ____________________________________                    ___________
                                                                                        (Date)
         o      Medical Library ______________________________________                  ___________
                                                                                        (Date)
         o      Pagers _____________________________________________                    ___________
                                                                                        (Date
         o      Remote Access Key Fob _______________________________                   ___________
                                                                                        (Date)
         o      Locker ______________________________________________                   ___________
                                                                                        (Date)
         o      Call Room Keys ______________________________________                   ___________
                                                                                        (Date)
         o      I.D. Badges (Return to GME at sign-out)__________________               ___________
                                                                                        (Date)
         o      Other ________________________________________________                  ___________
                                                                                        (Date)

GME Use Only
  (Date of Sign Out) ___________________________           Certificate   _____Yes     _____No

  Comments___________________________________________________________________

								
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