Supplemental Clinical Activity Request | UAMS Graduate Medical Education

Prior to completing this form, please review UAMS COM GMEC 3.310 Guidelines for Supplemental Activity

In order to complete this process, you will need to download the Resident/Fellow Acknowledgment Form, obtain signatures and upload the signed form.

GME provides approval for educational purposes only. Once GME approves, program will need approval for appropriate departmental and COM representatives.

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

Supplemental Clinical Activity Request Form

Name of Person Filling Out Form(Required)

First Last

Email of Person Filling Out Form(Required)

Program Director Name(Required)

First Last

Program Director Email(Required)

Training Program(Required)

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

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)

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 Location(Required)

Administrative Contact Name(Required)

First Last

Administrative Contact Phone Number(Required)

Administrative Contact Email(Required)

Description of Activity and Responsibilities of Resident/Fellow:(Required)

Average number of hours/week residents/fellows will participate in this activity:(Required)

Average number of times/week residents/fellows will participate in this activity:(Required)

Upload Signed Acknowledgement of Policy Document(Required)

from the Resident/Fellow

Max. file size: 15 MB.