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 ($100,171).
J-1 Visa Holders are required to complete an Intealth Attestation Form and submit it to the UAMS Immigration Office (AskImmigration@uams.edu). The immigration team will upload the form into MyIntealth on behalf of the program. The UAMS Immigration office’s confirmation email must be uploaded with the request. (The attestation form is available at www.ecfmg.org/evsp/supplemental-clinical-activity-attestation.pdf.)

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.

Please allow up to THREE weeks for the processing of Supplemental Clinical Activity requests.

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

* Please note: if any individuals are J-1 Visa Holders, an attestation form is required. To access the form, please enter the trainee separately as an individual and not part 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

Are they a J-1 Visa holder? (y/n)(Required)

Intealth Attestation Confirmation Email for J-1 Visa Holders(Required)

As described above, the attestation form confirmation email from UAMS Immigration must be uploaded for J-1 Visa Holders. Submit the Attestation Form to AskImmigration@uams.edu and upload the confirmation email here. (The form is available at www.ecfmg.org/evsp/supplemental-clinical-activity-attestation.pdf)

Max. file size: 15 MB.

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.

PD Email Address(Required)

File

Max. file size: 15 MB.

Website

Please allow up to THREE weeks for the processing of Supplemental Clinical Activity requests.