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
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.
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 “email@example.com”.
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
firstname.lastname@example.org 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: email@example.com. 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
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.
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
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
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? ___________
Name: __________________________________________________________ Relationship: ________________________________
Complete Mailing Address: ____________________________________________________________________________________________
Home Telephone: _________________________________________________ Other Telephone: ____________________________
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Medical/Dental School: ___________________________________________________________________ Degree: M.D.
_____________________ __________________________ _____________________ M.D., Ph.D.
City State Country M.D., D.D.S.
Date Degree Awarded in format (MM/DD/YYYY):__________________________________________________ D.D.S.
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
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.
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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.
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
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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
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TO BE COMPLETED BY DIRECTOR OF THE TRAINING PROGRAM IN WHICH THE HOUSE OFFICER IS CURRENTLY
CURRENT SPECIALTY: ___________________________________________________ PGY: ______________________
CURRENT TRAINING PROGRAM:
STREET ADDRESS SUITE/UNIT #
CITY STATE COUNTRY ZIP/POSTAL CODE
RESIDENCY COORDINATOR: PROGRAM DIRECTOR
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.
THIS SECTION TO BE COMPLETED BY THE PROGRAM DIRECTOR PROVIDING THE ELECTIVE:
DISAPPROVED _________________________________________________ ____________________
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.
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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,
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 (firstname.lastname@example.org), or via the confidential compliance hotline (888-
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:
_____________________________________________ 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
Revised 9/2010 ∙ Direct questions to email@example.com
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.
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
• 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
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
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
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
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
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
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