Extramural Rotation Request Form | UAMS Graduate Medical Education

Please review GMEC Policy 1.220 Extramural Experience (Rotation) prior to the completion of this form. Requests should be submitted at least 2 months prior to proposed date of proposed rotational experience. Required extramural rotations with new participating site locations must be approved by College of Medicine Graduate Medical Education Committee and program’s ACGME Review Committee, as appropriate. Program will be required to provide documentation as part of the submission of this form, which may include:

Funding source for rotation.
Documentation from UAMS Immigration approving rotation for resident/fellow on visa
Liability amount at rotation location and confirmation of UAMS liability coverage for rotation by UAMS General Counsel, Jennifer Smith.
Rotation Goals and Objectives
ACGME Program-Specific Requirement for educational experience
Verification of participating site in ACGME ADS

Extramural Rotation Request

This form will be submitted to the GME Office for review and approval. For questions please contact askgme@uams.edu.

"*" indicates required fields

Name of Person Filling out Request*

First Last

Email of Person Filling out Request*

Name of Program Requesting Rotation

Trainee's Name*

First Last

Trainee's Email

Trainee's PGY Level*

Trainee's Phone Number*

Do you have a source of payment for trainee salary/benefits while on the requested rotation?*

Yes

Funding Documentation*

Please submit documentation of proof that this rotation has support of funding.

Max. file size: 15 MB.

Rotation Information

Please select the type of extramural rotation you are requesting*

ACGME Required Extramural Rotation

Elective Extramural Rotation

Please copy and paste the requirement from your ACGME Program Specific Requirements*

Rotation Name*

Proposed Start Date of Rotation*

Length of Rotation*

Description of Rotation*

Board Eligibility*

I have looked at the board eligibility requirements and this rotation meets those requirements.

This rotation meets board eligibility requirements

Name of Participating Institution for the Extramural Rotation*

Address*

of the Participating Institution for the Extramural Rotation

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is this a new participating site for your program?*

Yes

Is this participating site listed in ADS/Are you able to add this site in the ADS?

Yes

Do your ACGME program requirements state that Review Committee approval is needed before adding a participating site?

Yes

Faculty/Physician Rotation Supervisor's Name*

First Last

Faculty/Physician Rotation Supervisor's Email*

Faculty/Physician Rotation Supervisor's Phone*

Funding

Required Rotation

Upload documentation (email) from Housestaff Office confirming approval of FTE allocated for funding this request.

Max. file size: 15 MB.

Elective Rotation

Upload documentation (email) from other funding source confirming approval of funding for this rotation.

Max. file size: 15 MB.

Goals and Objectives*

Please attach the goals and objectives for the rotation

Max. file size: 15 MB.

How will this rotation enhance the educational experience of trainees?*

What training deficiency at UAMS caused the program to need this rotation?*

How is this deficiency being addressed for future educational training?*

Liability Documentation

Program must confirm UAMS liability insurance rates will cover resident at training location site. Program must notify UAMS Insurance and Judicial Coordinator, Arnetia Dean, at ADean2@uams.edu, of extramural rotation and if needed, arrange additional insurance coverage.

Liability Documentation*

Program has confirmed with training location site that UAMS professional liability insurance amounts for UAMS COM residents/fellows of $500,000 per occurrence with $1,500,000 annual aggregate will cover the resident/fellow while working at the rotation site.

Yes

Liability Documentation*

Upload documented confirmation (email) from Jennifer Smith, of liability insurance coverage of resident/fellow while on extramural rotation.

Max. file size: 15 MB.

Liability Comments?

Additional comments about liability insurance coverage

UAMS Immigration documentation

If a resident is on a visa, the program must submit documentation from UAMS Immigration that the resident has been approved for an extramural rotation.

Max. file size: 15 MB.

Upload your program-specific extramural rotation policy.*

Max. file size: 15 MB.

Program Director's Name*

Program Director's Acknowledgement*

• I acknowledge this requested rotation meets the requirements outlined in my program’s policy on extramural rotations.
• I endorse the educational value that this rotation offers in the education of the trainee and have approved the rotation for the trainee listed above.
• I am aware that adequate supervision of the trainee must be provided at the participating institution.
• I acknowledge that communication has been made with the faculty supervisor at the rotating site regarding the educational goals and objectives, supervision and evaluation of the trainee during the rotation.

I am in agreement with the terms of the extramural rotation.

You must have a funding source before completing this form!