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					 Application for Visiting Elective Rotation

SUBMISSION DEADLINE: 8 WEEKS PRIOR TO START OF ROTATION




                  Office of Graduate Medical Education
The University of Texas Health Science Center at Houston Medical School
                    6431 Fannin Street, Suite JJL 310
                            Houston TX 77030
                              713-500-5151
                 Visiting Resident Elective Rotation Requirements
Space Availability. Participation in any election rotation will be allowed on a space-available basis.
Selection dates must have final approval from host department program director.

Status/Eligibility. Visiting residents must be currently enrolled in an ACGME or AOA accredited training
program and have completed the necessary training and didactic work for the training program.

ACLS or PALS Provider Certification. Visiting residents & fellows must submit proof of current
certification in ACLS Provider and/or PALS Provider. This is required by the hospital administration and
there are no exceptions.

Immunizations. Visiting residents & fellows must submit documentation of immunization for or lab
reports showing results of antibody titers for immunity to Tetanus-Diphtheria, Hepatitis B, Measles and
Rubella, Mumps, Chicken Pox (Varicella), and an annual Tuberculin skin test taken within six months of
the rotation start date.

Personal Health Insurance. Visiting residents must include with their application proof of personal health
insurance (send a copy of the insurance card).

License/Training Permit. Visiting residents who do not have their own Texas medical license or
Physician-In-Training Permit must complete the appropriate training permit application. Participation in an
elective rotation is contingent upon visiting resident’s ability to obtain the applicable training permit.

Malpractice Insurance. Proof of professional medical liability with coverage amounts no less than
$100,000/claim and $300,000/aggregate must be submitted with the application. NO MEDICAL
MALPRACTICE INSURANCE WILL BE PROVIDED BY THE UNIVERSITY OF TEXAS SYSTEM.

Affiliation Agreement. The University of Texas Health Science Center at Houston Medical School
requires an up-to-date affiliation agreement with the Home institution prior to the visitor's participation in
our training programs. The GME Office will forward this document to your Home Institution when your
application is approved.

Housing: Housing, Travel, Parking and Meals are not provided.

All of the above requirements must be met in order for your application to be considered complete. You
will be notified by the host program of the acceptance of your application. Completed applications must be
received by GME Office no less than four weeks prior to start of rotation.
                            Required Attachments
Residents interested in participating in elective rotations at The University of Texas Health
Science Center at Houston Medical School must complete the Elective Rotation Application and
submit it directly to the training program with which they wish to rotate for consideration.
Contact information for the individual programs can be found at the bottom of the GME Web
Page for visitors http://med.uth.tmc.edu/administration/gme/visitor.html.

The following items must be submitted with the application and are required for approval:

    1. Copy of Texas Medical License or Permit. Visitors outside of Texas should contact the
       Texas Medical Board for instructions on obtaining a Rotator Physician In Training
       Permit. They may be contacted at “pits@tmb.state.tx.us”.

    2. DPS Statement – Copies of DEA and DPS certificates must be attached

    3. Proof of malpractice coverage
       with minimum coverage of $100,000 per occurrence & $300,000 in aggregate.

    4. Photocopy of a CURRENT ACLS Provider certification. PALS should be submitted for
       Pediatric rotations. This is a requirement of the hospital and there are NO exceptions.

    5. Photocopy of medical diploma & ECFMG if applicable

    6. Applicant’s current curriculum Vitae

    7. Photocopy of driver’s license & resident alien card

    8. Completed UT IT Accountability Form

    9. Completed immunization record – All listed items are required

    10. Proof of current health insurance coverage (photocopy of insurance card)

    11. Passport Photo for badge that meets attached requirements.


      Faxed applications will not be accepted.
                                      Out of State Rotator Information

The out of state residency program director and coordinator must send an email to
pit.applications@tmb.state.tx.us to request the necessary information and documents to initiate the process
for a rotator physician in training permit.

Applications for a physician-in-training permit shall be submitted to the board no earlier than the 120th day
prior to the start date of the rotation to ensure the application information is not outdated. To assist in the
expedited processing of the application, the application should be submitted as early as possible within the
sixty-day window prior to the date the applicant intends to begin the rotation in Texas.

Higher complexity applications will require additional processing time due to documentation requirements
and review process.

                                Physician in Training (PIT) Permit Process

1. The out of state residency program director and coordinator sends the completed spreadsheet along
   with the required certification to TMB at: pit.applications@tmb.state.tx.us. The program director must
   be included in all spreadsheet submissions and communications to the TMB.

2. The TMB will process the submission and then return the spreadsheet to the program director and
   coordinator with the TMB personal ID number and links to the online application.

3. The resident goes online to complete the application and attestation. The fee is $120 and can be paid
   with an electronic check or major credit card. The resident cannot apply prior to Steps 1 and 2.

4. The Texas Licensed physician supervising the rotation(s) in Texas is required to submit a statement to
   the TMB that certifying certain details related to your rotation.

5. Rotator permits are limited to the dates of the rotation in Texas. The permit will reflect the name and
   address of the out of state postgraduate training program, not the Texas program where the rotation is
   being completed.

6. Some documentation may be required before the issuance of a permit may be considered. The TMB
   will communicate with resident at the mailing address and/or email address listed on their application.




                                                                                                        11.08/np
                      THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON
             MEDICAL SCHOOL AFFILIATED HOSPITALS INTEGRATED RESIDENCY TRAINING PROGRAM
                                APPLICATION FOR VISITING HOUSE STAFF

TO BE COMPLETED BY THE RESIDENT OR CLINICAL FELLOW APPLYING FOR ELECTIVE:
SPECIALTY / SUBSPECIALTY WHERE YOU WISH TO ROTATE:       ____________________________________________________________

INCLUSIVE DATES OF ROTATION:    __________________________________                ____________________________________
                                        START DATE                                                END DATE

APPLICANT INFORMATION
FULL NAME:       ____________________________________________________________________________________________________
                 FIRST NAME                              MIDDLE NAME                     LAST NAME

HOME ADDRESS:    ____________________________________________________________________________________________________
                 STREET ADDRESS                                                          APARTMENT/UNIT #

                 ____________________________________________________________________________________________________
                 CITY                                    STATE                   COUNTRY         ZIP/POSTAL CODE

HOME PHONE:      ______________________________          PAGER NUMBER:    ____________________________________________

CELL PHONE:     ______________________________          PERMANENT E-MAIL ADDRESS:       ____________________________
********************************************************************************************************************
Alternate Name Documentation:              Each applicant who has recorded an alternate name on this
application from that shown on their attached supporting documents must submit copies of documents
that will support the name change. Those documents could be a marriage certificate, divorce decree, court
ordered name change or some other official document.
********************************************************************************************************************

U.S SOCIAL SECURITY NUMBER:     ________________________________


BIRTH DATE: ____________________         PLACE OF BIRTH: ______________________________________________________
                                                         CITY                  STATE                COUNTRY

GENDER:            FEMALE       MARITAL STATUS:     SINGLE
                   MALE                             MARRIED

ARE YOU A U.S. CITIZEN?            YES
                                   NO    → COUNTRY OF CITIZENSHIP? _______________________________________

                                ARE YOU A PERMANENT RESIDENT?        YES → ATTACH A PHOTOCOPY OF YOUR “GREEN CARD”
                                                                     NO → WHICH VISA WILL YOU APPLY FOR?  ___________




EMERGENCY CONTACT

Name: __________________________________________________________          Relationship: ________________________________

Complete Mailing Address: ____________________________________________________________________________________________

Home Telephone: _________________________________________________         Other Telephone: ____________________________




                                                          1 of 5
ACADEMIC HISTORY


Medical/Dental School: ___________________________________________________________________ Degree:              M.D.
                                                                                                                D.O.
                                                                                                                M.D., M.P.H.
_____________________               __________________________                     _____________________        M.D., Ph.D.
City                                State                                          Country                      M.D., D.D.S.
                                                                                                                M.D., D.M.D.
Date Degree Awarded in format (MM/DD/YYYY):__________________________________________________                   D.D.S.
                                                                                                                D.M.D.

A. List any other Medical/Dental Schools attended in chronological order, beginning with the most recent institution.
Do not abbreviate names.

          Date Started                               Date Left                                     Medical School
            (mm/dd/yy)                              (mm/dd/yy)                                    City/State/Country




B. List any graduate school training in chronological order, beginning with the most recent institution.
Do not abbreviate names.

               Dates                          Graduate Institution                          Area of Study               Degree
        From             To                      And Address                                                           Awarded
  (mm/dd/yy)          (mm/dd/yy)                                                                                        (if any)




C. List all residency/fellowship training in chronological order, beginning with the most recent institution.
Do not abbreviate names.

              Dates                          Sponsoring Institution                        Specialty Name              PGY Level
       From             To                       And Address
  (mm/dd/yy)        (mm/dd/yy)




 I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading
 information may result in my release from the training program.

 Signature:                                                                                         Date:
                                                                  2 of 5
The United States Department of Education requires all state and local education institutions to collect data on ethnicity
and race for students and staff. This information is used for state and federal accountability reporting as well as for
reporting to the Office of Civil Rights and Equal Employment Opportunity Commission.

Please answer both parts of the following questions on your ethnicity and race. United States Federal Register (72 Fed.
Reg. 59266)

Part 1: Ethnicity

Do you classify yourself as Hispanic/Latino? (Choose only one.)

    •      Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
        culture or origin, regardless of race.
    •      Not Hispanic/Latino

Part 2: Race

What is your race? (Choose one or more.)

    •      Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
        subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
        Islands, Thailand, and Vietnam.
    •      Black - A person having origins in any of the black racial groups of Africa or the Caribbean.
    •      Native American or Alaska Native - A person having origins in any of the original peoples of North and
        South America (including Central America), and who maintains tribal affiliation or community attachment.
    •      Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of
        Hawaii, Guam, Samoa, or other Pacific Islands.
    •      White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

************************************************************************************************************************

 FULL RELEASE OF THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON MEDICAL SCHOOL
      AFFILIATED HOSPITALS INTEGRATED RESIDENCY TRAINING PROGRAM FROM ALL LIABILITY


I understand that in connection with my voluntary participation in the clinical training experience at The University of
Texas Health Science Center at Houston Medical School Affiliated Hospitals Integrated Residency Training Program, I
will be offered the opportunity to work in hospital or clinic settings, which may be hazardous. In these settings, I may
come into contact with:


    1. Communicable or infectious diseases, including by way of example, tuberculosis, HIV, hepatitis;
    2. radioactive devices and substances;
    3. biologically hazardous materials;
    4. dangerous equipment;
    5. and other substances or things which are unfamiliar to me and which could cause serious injury to me, including
        death.

                                                           3 of 5
Additionally, I may be exposed to other potentially harmful situations and equipment commonly encountered in a medical
environment where patients are treated, such as operating suites, emergency departments, labor and delivery suites, and
intensive care units. As a result of the hazardous environment at the school and its affiliated hospitals and clinics, I
understand that there is the potential for me to be seriously injured or even killed.


In consideration of the experience and training which I will receive at The University of Texas Health Science Center at
Houston Medical School Affiliated Hospitals Integrated Residency Training Program, which I expressly state will be of
great value to me and my career and which will greatly enhance my educational experience as a physician in training, I,
__________________________________________________, do hereby release and hold harmless The University of
Texas System, its regents, officers, employees, faculty, staff and all other persons, firms, subsidiaries, corporations or
other entities, including the affiliated hospitals and clinics which might be liable, from any and all claims, demands,
lawsuits, causes of action, known or unknown, of whatever nature whether for personal injury (including a serious
disease) or death, or otherwise which may accrue through my voluntary participation in clinical training in The University
of Texas Health Science Center at Houston Medical School Affiliated Hospitals Integrated Residency Training Program.


____________________________________________                          ___________________________________
Signature of Applicant                                                Date




                                                             4 of 5
TO BE COMPLETED BY DIRECTOR OF THE TRAINING PROGRAM IN WHICH THE HOUSE OFFICER IS CURRENTLY
ENROLLED:

CURRENT SPECIALTY:       ___________________________________________________        PGY:    ______________________

CURRENT TRAINING PROGRAM:

                 ____________________________________________________________________________________________________


                 ____________________________________________________________________________________________________


                 ____________________________________________________________________________________________________
                 STREET ADDRESS                                                          SUITE/UNIT #

                 ____________________________________________________________________________________________________
                 CITY                                    STATE                   COUNTRY         ZIP/POSTAL CODE

PROGRAM CONTACTS

RESIDENCY COORDINATOR:                                               PROGRAM DIRECTOR

PRINTED
NAME: ______________________________________________                 ____________________________________________________

PHONE:   ______________________________                              ____________________________________________________

E-MAIL: ______________________________                               ____________________________________________________


 I certify that the house officer described on this application is currently in good standing in this program and has been
 approved to participate in this elective rotation.

 Signature:                                                                                 Date:

**********************************************************************************************
THIS SECTION TO BE COMPLETED BY THE PROGRAM DIRECTOR PROVIDING THE ELECTIVE:

   APPROVED
   DISAPPROVED           _________________________________________________                  ____________________
                         SIGNATURE                                                          DATE

THE HOUSE OFFICER SHOULD REPORT TO:

______________________________________________            ____________________________________________
PERSON                                                    ON THIS DATE/TIME

______________________________________________            ____________________________________________
LOCATION                                                  ROOM NUMBER

HOUSE OFFICER WILL ROTATE AT THIS HOSPITAL(S):            ______________________________________________________

TO BE COMPLETED BY THE UTHSC-H GRADUATE MEDICAL EDUCATION OFFICE


 I certify that the house officer described on this application has supplied all required documentation and is approved for
 participation in an elective rotation.

 Signature:                                                                                 Date:

                                                            5 of 5
                                 Information Resources User Acknowledgement Form


The University of Texas Health Science Center at Houston (UTHealth) information resources are owned by UTHealth and
are provided to accomplish UTHealth’s mission. Users must use UTHealth information resources appropriately to ensure
availability and preserve information integrity and confidentiality. A user is anyone who is granted access to a UTHealth
information resource, including, but not limited to faculty, students, residents, staff, alumni, retirees, continuing and
distance education students, researchers, principal investigators, visiting faculty, business partners, contractors,
vendors, consultants.

Use of UTHealth information resources is subject to UTHealth and University of Texas System (UT System) policies and
state and federal laws which include, but are not limited to: UTHealth Information Technology policies and procedures
posted in the IT Policy & Document Repository; UTHealth Handbook of Operating Procedures (HOOP) 175
“Responsibility for the Use of Information Resources”; HOOP 180 “E-mail and Internet Usage”; UT System policy 165 “UT
System Information Resources Use and Security Policy”. Failure to comply with these policies may result in disciplinary
action including termination of employment, professional/business relationship, or dismissal from school. Civil and/or
criminal sanctions may apply.

I acknowledge I understand my role in protecting information resources. I will uphold/comply with applicable laws
and the policies noted above, including the following:
    1. UTHealth information resources must be secured from unauthorized intentional and/or accidental access.
        Unauthorized modification, disclosure and/or destruction of data are prohibited.
    2. All passwords to information resources including, but not limited to, network accounts, computer accounts,
        encryption software, voice mail and long distance telephone codes must not be shared with anyone. Disclosing
        a password may result in immediate termination of employment, professional or business relationship, or
        dismissal from school.
    3. UTHealth information resources are only to be used for UTHealth business.
    4. Users should have no expectation of privacy regarding e-mail use, internet use or other activities performed on,
        or information processed by or residing on, UTHealth information resources.
    5. Sensitive and confidential data must be stored on appropriate network drives. If it must be saved on a portable
        device (e.g. external hard drive, USB device, DVD, CD, etc.), it must be encrypted and saved only temporarily.
    6. Software or electronic media or files (e.g. music, videos, e-books) may not be downloaded, copied or otherwise
        used in violation of licensing agreements and/or copyright.
    7. Users are subject to random, unannounced inspection audits to ensure compliance with all UTHealth and UT
        System policies and state and federal laws.
    8. It is the responsibility of all users to report any suspected or confirmed violations to appropriate management,
        to the Chief Information Security Officer (ciso@uth.tmc.edu), or via the confidential compliance hotline (888-
        472-9868).
    9. All sensitive and confidential information, including research data, SSNs, and information protected by HIPAA
        and FERPA, must be protected in accordance with UTHealth policies, UTS 165 and state and federal laws.
    10. Users must complete all required initial and recurring information resource training.

PRINT First Name                               Middle                      Please check one and provide ID or A# if known:
                                               Initial:
               _____________________________________________                 Employee ID: _________________________
PRINT Last Name                                                              Student A#: __________________________
              _____________________________________________                  Resident/House Staff ID: ________________
                                                                             Guest ID: ____________________________
SIGNATURE:       _____________________________________________             Guests who are contractors or consultants must also
                                                                           sign the Contractor Confidentiality Acknowledgement
                                                                           form.
DATE:           _____________________________________________

                                Revised 9/2010 ∙ Direct questions to itcompliance@uth.tmc.edu
                         DPS Suffix Statement and Certification




Effective September 1, 2008, the HSC Sec. 481.074(k) required a DPS registration number to be
included on all controlled substances prescriptions. To comply with the legislative requirements,
permitted persons will be allowed to prescribe controlled substances utilizing the institution’s
DPS and DEA registration numbers followed by the permitted person’s unique suffix. If the
permitted person changes institutions/hospital for any reason during their participation in the
training program, then they should use the registration numbers and unique suffixes for the
institution/hospital training program they are participating in when prescriptions are issued.
According to the Texas Health and Safety Code, licensees are not authorized to utilize an
institution’s registration numbers for controlled substance prescriptions. Since licensees have a
valid license with their respective licensing board, they are required to obtain their own DPS and
DEA registration numbers.

Persons participating in the Texas Medical Board Physician in Training program must have a
DPS number for all controlled substance prescriptions they issue. The DPS PIT number will be
assigned by either the affiliated hospital or GME office on behalf of the physician in training.
The DPS PIT number is only valid for the duration of the training program.

Suffix numbers will be distributed through your program once you start.

I certify that I have never had an application for the DEA registration denied and never had a
DEA registration revoked.

________________________________
Print Name

________________________________
Signature

________________________________
Date


ALL LICENSE HOLDERS MUST SUBMIT A COPY OF THEIR DEA AND
           DPS CERTIFICATES WITH THIS PACKET.
Photograph Requirement Form for Badge
Please read carefully and follow the instructions and provide
a photo as indicated below

Your photograph must be:

•      MUST BE PASSPORT PHOTO - 2x2 inches in size
•      Taken within the past 2 months, showing current appearance
•      Color
•      Full face, front view with a plain white background
•      Between 1 inch and 1 3/8 inches from the bottom of the chin to the top of the head

    Taken in normal street attire, colored or dark clothing. No white T-shirts or white
    shirts as they do not appear on the badge.

       o      Uniforms should not be worn in photographs. No lab coats or scrubs.
       o      Do not wear a hat or headgear.
       o      If you normally wear prescription glasses they should be worn for your
              picture.
       o      Dark glasses or nonprescription glasses with tinted lenses are not
              acceptable unless you need them for medical reasons. A medical certificate
              may be required.

Vending machine photos, home-made photos, scanned or copied
photos are not acceptable. Must be made at an official Passport
location!

REMEMBER: This photograph will be used for your University of Texas I.D. Badge
which must be displayed on you at all times while in clinic and on service at the
hospitals.

If you do not submit a photo in the above format you will be required to obtain a
badge form from the GME Office to have a photo taken after you check-in with the
program you will be working with. Photos and badges are not made at the Medical
School and you will not be allowed to check in with the hospital or start any
rotations without your I.D. Badge.

PLEASE INSERT YOUR PHOTO IN AN ENVELOPE AN ATTACH HERE
                           UT­Houston Medical School Health Service 
              6410 Fannin, Suite 510 PHONE: (713) 500‐5171 Fax: (713) 500‐0605 
                                               
                               IMMUNIZATION REQUIRMENTS 
 
This must be completed and turned in prior to your UTHSC Orientation day. Should 
you be in the Houston area, you may process this form at the Student Health 
Service clinic. They can pull required titers and administer immunizations for a 
nominal fee. Contact them at the number above for an appointment. Take the 
form with you to your appointment. Please return this completed form to the 
Graduate Medical Education Office with your packet. Do not send it to or leave it 
with the Medical School Health Service clinic. You will be cleared to begin your 
training program only after you meet all requirements listed on this form.  You 
must attach supporting documentation of all vaccines, titer results. Do not attach 
original documents. Submit photocopies only. Your records will not be returned. 
 

 

     REQUIRED IMMUNIZATIONS                               MINIMUM REQUIREMENT 
     Tetanus Diphtheria and Pertussis ‐ Tdap    One dose within the past 10 years. Only brand names of 
                                                Adacel (Tdap) or Boostrix (Tdap) satisfy this requirement. 
     Measles (Rubeola)                          Two (2) doses of measles vaccine if born after January 1, 
                                                1957 administered on or after your first birthday and at 
                                                least 30 days apart; or lab report of positive rubeola titer 
     Mumps                                      One dose of mumps vaccine administered on or after first 
                                                birthday; or lab report of positive mumps titer 
     German Measles (Rubella)                   One dose of rubella vaccine administered on or after first 
                                                birthday; or immunity to rubella by presenting a lab report 
                                                of positive rubella titer 
     PPD (TB) Skin Test                         Within the past 6 months, even for those who have 
                                                received BCG vaccine as a child.  If PPD skin test is positive, 
                                                a chest x‐ray documenting no active tuberculosis must be 
                                                submitted with immunization form 
     Hepatitis B Series                         Three‐dose series (second dose one month and third dose 
                                                six months after first dose) or lab report of positive 
                                                hepatitis surface antibody titer. Must be vaccinated to 
                                                most current status possible prior to registering for 
                                                classes. 
     Varicella (Chicken Pox)                    A lab report of positive varicella titer is required. If the 
                                                titer is negative, then two‐dose series (second dose one 
                                                month after first dose) is required followed by a lab report 
                                                of positive varicella titer. History of illness is NOT 
                                                sufficient. 
 
                                                 IMMUNIZATION REQUIRMENTS 
 

Last Name: ______________________                          First Name: ___________________                  Middle Initial: ______ 

USA Social Security Number: _______________________                           Date of Birth: __________________________ 

                                                 All dates in the format of MM/DD/YYYY 

Tetanus‐Diphtheria‐Pertussis vaccine (Tdap):This requirement is only satisfied by brand names of Adacel or Boostrix  

__________________           within last ten years 

 

 

Hepatitis B # 1: _____________                                                HBsAB Titer Date 1: ____________          Result: ____________ 

Hepatitis B # 2: _____________                                                if negative  Hepatitis B (Booster): ______________________ 

Hepatitis B # 3: _____________                                                HBsAB Titer Date 2: ____________          Result: ____________ 

 

 

Measles vaccine # 1: _____________                                            Measles Titer 1: _______________          Result: _____________ 

Measles vaccine # 2: _____________                                            if negative  Booster Shot: _______________ 

Mumps vaccine: _____________                                                  Mumps Titer: _________________            Result: _____________ 

                                                                              If negative  Booster Shot: _______________ 

Rubella vaccine: _____________                                                Rubella Titer: _________________          Result: _____________ 

‐OR‐                                                                          If negative  Booster Shot: _______________ 

MMR vaccine # 1:________________                  MMR vaccine #2: __________________ 

 


A titer is REQUIRED by everyone 

Varicella Titer 1: _________________             Result: _______________      If negative        Varicella vaccine # 1: ______________ 

                                                                                                  Varicella vaccine # 2: ______________ 

Varicella Titer 2: ________________              Result: _______________ 

 

Must be within the last 6 months. 

PPD      Date Administered: ________________               Date Read: __________________          Reading: ______ mm in duration 

If positive  Chest X‐ray Taken: ________________          X‐ray Result: __________________       INH Prophylaxis?  Yes          No 

				
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