Transfer Request Form Transfer Request Form GMEC Policy 1.2.10 on Residents Transferring Between Residency Program states that the receiving program director will obtain the following information for credential review: Resident/Program InformationResident's Name * Required First Last Current Residency Program Name * Required Current Residency Program Director's Name * Required Current Residency Program's Location * RequiredPlease list name of hospital, city, and state. Receiving Residency Program Name * Required Receiving Residency Program Director's Name * Required Receiving Residency Program Director's Email Transfer Verification InformationACGME Compliance * Required I certify that this resident is eligible in compliance with the institutional and specific program requirements of the ACGME. Financing for the position * RequiredThe receiving Program Director should contact the Associate Dean for Housestaff Affairs to discuss/assure funding. Please list the financing for the position including: stipend level, source of stipend/benefits, and remaining Centers for Medicare/Medicaid Services (CMS) funding on the resident’s initial residency period (IRP)Written acknowledgement from current PD * RequiredIt is unethical for discussions regarding specific positions or arrangements to occur either at UAMS-COM or elsewhere without written acknowledgement from the current Program Director about transfer discussions. Please attach this written acknowledgement.Max. file size: 15 MB.What is the resident's reason for changing programs? * RequiredPlease attach a minimum of the previous 6 months competency based clinical evaluations or summative competency based performance evaluation. * Required Drop files here or Select files Max. file size: 15 MB. Please upload verification of completed educational experiences. * Required Drop files here or Select files Max. file size: 15 MB. Are case logs required for this transfer? * Required Yes No If yes, please attach the case logs here. Drop files here or Select files Max. file size: 15 MB. Any other documentation to verify that the trainee meets comparable level of program's current traineesAny other documentation to verify that the trainee meets comparable level of program's current trainees Drop files here or Select files Max. file size: 15 MB.
