Supplemental Clinical Activity (SCA) Request | UAMS Graduate Medical Education

Prior to completing this form, please review UAMS COM GMEC 3.310 Guidelines for Supplemental Activity This online form must be completed by the Program Director or Program Coordinator.

In order to complete this process, you will need to:

Download the Resident/Fellow Acknowledgment Form, obtain signatures and upload the signed form.
Upload documentation showing approval from SCA department business administrator for the requested SCA.
- It is the responsibility of the department to ensure SCA pay and UAMS salary does not exceed the Arkansas State line-item maximum ($90,715).

GME provides approval for educational purposes only.

Residents and fellows are NOT authorized to begin supplemental clinic activities until Program Director has received approval from the Designated Institutional Official. The GME Office will provide confirmation of the approval to the program.

Supplemental Clinical Activity Request Form

Name of Program Director or Program Coordinator submitting SCA Request(Required)

First Last

Training Program(Required)

Is this request for a group of trainees or an individual trainee?(Required)

Group

Individual

List Each Individual of the Group

Trainee's Name

PGY Level

Are they a US citizen?

Visa status if not US citizen

Trainee's Name(Required)

First Last

PGY Level(Required)

Email(Required)

Are they a US Citizen?(Required)

Yes

What is thier Visa status?(Required)

Separate from my duties as a housestaff officer at UAMS, I/they request to be employed for the academic year selected below at the following location.(Required)

Approval is granted for 12 months or less during a single academic year (July 1 – June 30)

Name of UAMS Department or Clinic for SCA(Required)

SCA Departmental Administrative Contact Name(Required)

First Last

SCA Departmental Administrative Contact Phone Number(Required)

SCA Departmental Administrative Contact Email(Required)

Provide a detailed description of duties that will be performed under SCA.(Required)

Provide details of proposed SCA work hours during a typical month.(Required)

EX: Number of times SCA will occur, number of hours worked during a SCA, number of days worked.

Upload Program-Specific Supplemental Clinical Activity Policy(Required)

Max. file size: 15 MB.

Upload Signed Resident/Fellow Acknowledgement of Policy Document(Required)

Max. file size: 15 MB.

Upload Documentation from Department Business Administrator approving SCA(Required)

Max. file size: 15 MB.