Resident and Fellow
Appointment Manual
Office of Graduate Medical Education
School of Medicine
University of California, San Francisco
April, 2015
Table of Contents
Introduction
Main Appointment Season Process
Off-Cycle Appointment Process
Appointment Process
New and Continuing Paperwork
APeX Access
1
1
1
2
2
2
Appointment Documents
Contract Letter
Attestation
California Medical Licensing Requirements
CV
Respiration Clearance Form
Abuse Reporting For
HIPPA Confidentiality Statement
Health Statement
Competencies or Privileges and Non-ACGME Fellows
Visa
ECFMG Certificate
3
3
4
6
8
8
8
8
9
14
16
16
E*Value Entry
General Requirements for E*Value
New Trainees in E*Value
Required E*Value Fields
Biographic Tab
Roles, Groups, and Specialties Tab
Training and Education Tab
Exam Scores Tab
Contact Tab
Miscellaneous Tab
17
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17
18
19
21
22
24
25
26
INTRODUCTION
In order to provide patient care at UCSF Medical Center, San Francisco General Hospital, and San Francisco
VA Medical Center, all residents, clinical fellows, and non-MD trainees in the School of Medicine must be
appointed through the Office of Graduate Medical Education (OGME). The majority of UCSF trainees are
appointed for June/July start dates.
There are two systems that are central to the appointment process: UCMe and E*Value. All appointment
paperwork is completed and submitted in UCMe. E*Value, the UCSF GME management system, serves as
the database of record for all GME training at UCSF. Access to both systems may be obtained from the
Office of GME.
All paperwork and appointment requirements are reviewed and revised annually and made available by the
beginning of February for the following academic year.
This manual provides information on how to appoint a UCSF trainee as well as appointment-related policies
and regulations. While the majority of paperwork is automatically populated based on the information
entered by both the program administrator and trainee in UCMe, samples of the individual forms and details
about what each form requires are provided to guide the program administrator.
All paperwork should be submitted in accordance with the appropriate deadlines as described below and as
complete as possible. Program administrators may submit incomplete packets if the missing documentation
is a medical license, PTAL, and/or visa.
Main Appointment Season Process
For appointment season (February through July) there are three rolling deadlines to submit paperwork to
OGME and complete the E*Value entry (please see the OGME website for deadlines). OGME will send the
program administrator a spreadsheet documenting what is complete and what is missing in both the packet
and E*Value within two weeks of the deadline. Program administrators have two weeks to submit missing
documentation through UCMe to OGME. Anything not submitted by this date is considered late. OGME
receives approximately 1,500 appointment packets during this time and cannot guarantee that trainees will
start on time if the packet or materials are not submitted by the assigned appointment deadlines.
In order to comply with UCSF GME policy, all continuing appointments must be initiated in UCMe at least
four months prior to reappointment date. For June/July start dates, this is no later than February 28th.
Off-Cycle Appointment Process
For off-cycle appointments, all paperwork must be submitted to OGME through UCMe at least one month
prior to the scheduled start date. If the packet is submitted less than one month before the start date, OGME
cannot guarantee the trainee will start on time. After the program administrator submits the packet, OGME
will review the packet and E*Value. OGME will work with the program administrator until the paperwork
and E*Value are approved. In order to comply with UCSF GME due process policy, all continuing
appointments must be initiated in UCMe at least four months prior to reappointment date.
1
Appointment Process
1. The program administrator initiates the paperwork in UCMe. After the required information has been
entered, an email is sent to the trainee notifying him/her to complete the paperwork. Detailed
instructions for how to use UCMe may be found at http://meded.ucsf.edu/gme
2. The trainee completes the paperwork and submits it through UCMe to the program administrator.
The program administrator works with the trainee as necessary to complete the paperwork.
3. The program administrator prints the documentation from UCMe that requires programmatic
signatures.
4. The program administrator has the program director review and sign the contract letter and
attestation.
5. The program administrator has the department chair sign the contract letter.
6. The program administrator uploads the signed documents back into UCMe.
7. The program administrator enters the trainee biographic information into E*Value.
8. The program administrator submits the packet through UCMe to the Office of GME (OGME).
9. OGME reviews the paperwork and E*Value entry and works with the program coordinator until both
are complete and approved.
10. Once the packet is complete:
a. New: OGME will order a background check. Once the background check is cleared, OGME
will assign a provider ID for trainees who have competencies and email the provider ID to the
program coordinator.
b. Continuing: OGME updates the trainee’s competencies as necessary in Echo.
Please note, the UCSF Medical Staff Office assigns provider IDs for non-ACGME fellows with privileges.
Program administrators should call the Medical Staff Office for these provider IDs.
New and Continuing Paperwork
Trainees are appointed annually either as new or continuing. New trainees have never been appointed in a
UCSF GME program. UCSF medical students, UCSF postdocs, etc. being appointed to a UCSF GME
program for the first time are considered new. Continuing trainees have been appointed to a UCSF GME
program in the past, either in the same program or in another program. For example, a current UCSF resident
becoming a UCSF clinical fellow in the next academic year would be considered a continuing appointment.
The exception to this rule is if there has been more than a year since the trainee’s previous UCSF program
ended and a new packet will be required.
APeX Access
APeX access will be granted automatically a few days after the provider ID is issued for new trainees with
competencies (program coordinators should not request APeX access from IT or through the ARF system).
For non-ACGME fellows with privileges, APeX access is only granted once it has been requested by the
program through an ARF.
Residents and fellows must complete the required online APeX training prior to starting their first rotations
at UCSF. Training modules are available on the UCSF learning management system
(https://learningcenter.ucsfmedicalcenter.org). Once a trainee has been entered into E*Value and has a UCSF
employee ID number, he/she may access the learning management system and take any required training
modules, including those for APeX.
2
CHECKLIST
•
•
•
•
The checklist is the coversheet of every packet submitted.
All of the information must be filled out at the top of the checklist (i.e. Trainee Name, Program
Name, PGY, Salary, Program Coordinator, and Program Director).
Check off all of the documents included in the packet.
Packets should be complete at the time of submission, with the exception of licenses, PTALs and
visas. If any documents are missing, comments should be included in the notes section.
CONTRACT LETTER
•
•
•
•
•
•
•
•
Contract letter templates are updated each year by OGME and are automatically generated in UCMe.
Only approved templates may be used, but if additional information is required, an addendum may be
written, signed, and uploaded to UCMe as an additional document.
The following templates are available in UCMe:
o Continuing Contract Letter, ABMS Fellow
o Continuing Contract Letter, ACGME Resident
o Continuing Contract Letter, ACGME Fellow
o Continuing Contract Letter, Non-ACGME Fellow
o New Contract Letter, ABMS Fellow
o New Contract Letter, ACGME Resident
o New Contract Letter, ACGME Fellow
o New Contract Letter, Non-ACGME Fellow
Letters for continuing residents and fellows must be initiated in UCMe and sent to trainees at
least four months prior to reappointment date. For June/July start dates, this is no later than
February 28th. The contract letter must be submitted to OGME with the appointment packet.
Use salaries for the current academic year (i.e. for June/July 2014 start date, the 2013-2014 salary
scales would be used). Salary scales can be found on the OGME website and will be automatically
populated in UCMe.
Electronic signatures are not allowed. Documents must be printed from UCMe, signed by hand, and
then uploaded back into the system.
The program director and chair sign the contract letter after the trainee has signed the contract and
completed the attestation. This allows for the program director to review the attestation prior to
signing the contract letter, making the offer official.
Postgraduate year (PGY) is based on the training required to be in the program as well as the number
of years a trainee has completed. All trainees in the same year of the program must have the same
PGY year.
o For example: Pediatric cardiology (requires the completion of a three year pediatric
residency)
 First year fellows always start pediatric cardiology as PGY4s.
• Fast trackers have completed two years of pediatrics residency and start
pediatric cardiology as PGY4s.
• Someone who has completed a chief resident year prior to starting fellowship
would have completed three years of pediatrics residency plus one year as a
chief resident and will start pediatric cardiology as a PGY4.
3
ATTESTATION
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•
•
•
•
•
•
•
•
New trainees fill out a two-page attestation.
Continuing trainees fill out a one-page attestation (page with yes/no questions).
All dates on the attestation must be in MM/DD/YYYY format.
For examinations, date and pass/fail status must be provided.
All postgraduate training and previous employment since medical school must be documented, with
the exception of gaps of less than 90 days between medical school and the PGY1 start date.
All questions must be answered.
If the trainee, has a “Yes” answer to any one of the questions a brief explanation as to why the trainee
answered yes must be provided. The explanation must include a description of the incident/event,
date of the incident, and the outcome of the situation (i.e. the current status of the legal proceedings).
If the trainee answered “Yes” in a prior year’s appointment packet he/she must resubmit an
explanation each year.
All signatures must be original and dated.
Mi, Do Re
Name (Last, First Middle)
999-99-9999
Social Security Number
Attestation (New Appointment)
Office of Graduate Medical Education
University of California, San Francisco
2014-2015
Complete this form truthfully and in its entirety and sign below. The attached offer of a training position at UCSF is dependent upon the results of your signed
attestation statement and its review by the program. Any “yes” response requires an explanation on a separate page. After review of your explanation of “yes”
statements, our offer of a contract for training may be revoked or the conditions of the offer revised.
Medical Education
List each medical school you have attended.
Name of School
City, State, Country
University of Minnesota
Minneapolis, MN 55455
Date of Attendance
(mm/dd/yyyy – mm/dd/yyyy)
08/01/2002-05/30/2009
Degree(s)
MD, PhD
Examinations
List all of the following exams you have taken: USMLE, COMLEX, FLEX, NBME, SPEX, QME, state boards.
Examination
Date (mm/dd/yyyy)
Pass/Fail
USMLE 1
USMLE 2 CK
USMLE 2 CS
USMLE 3
Institution/Location
University of Michigan
University of Michigan
University of Michigan
University of Michigan
Hospital Británico de Buenos
Aires
BREAK/Relocation to San
Francisco, CA
04/12/2007
PASS
10/30/2008
PASS
03/15/2009
PASS
07/22/2010
PASS
Postgraduate Training, Previous Employment, and Malpractice
List all postgraduate training and employment since receiving medical degree.
PLEASE ACCOUNT FOR ALL TIME SINCE GRADUATION (I.E. TIME STUDYING ABROAD).
PGY
Dates
City, State, Country
Specialty/Activity
Level
(mm/dd/yyyy – mm/dd/yyyy)
Ann Arbor, MI USA
Pediatrics
1
06/15/2009-06/30/2010
Ann Arbor, MI USA
Pediatrics
2
07/01/2010-06/30/2011
Ann Arbor, MI USA
Pediatrics
3
07/01/2011-06/30/2012
Ann Arbor, MI USA
Chief Resident
4
07/01/2012-06/30/2013
Buenos Aires, Capital Federal,
Buenos Aires, ARGENTINA
N/A
Pediatric Research Abroad
N/A
07/01/2013-04/30/2014
N/A
N/A
05/01/2014- 06/30/2014
4
Mi, Do Re
Name (Last, First Middle)
999-99-9999
Social Security Number
Any “yes” response to the questions below requires a detailed explanation on a separate page. Failure to provide an adequate explanation may result in the delay or rejection of your (re)appointment.
1. Has any medical malpractice judgment been entered against you in any professional liability case(s)?
Yes
No
2. Has any settlement been made in any professional liability case in which you or your insurance carrier had to or agreed to make a monetary payment?
3. Are you aware of any malpractice claims currently pending/under investigation against you?
4. Has any policy been canceled, or has any professional liability insurer refused to renew your policy or placed limitations on the scope of your coverage?
Yes
Yes
Yes
No
No
No
5. Do you currently have, or have you had a problem associated with the use or misuse of drugs or controlled substances of any kind (whether obtained by prescription or
otherwise), or alcohol? If yes, on a separate sheet please give a full explanation, including, without limitation, frequency and amount of use, the time period in which you
engaged in such use, and the date last used.
6. Do you have any reason you cannot safely perform all the essential mental and physical functions related to the specific clinical privileges you are requesting or required by
your agreement with your training program and the School of Medicine, with or without reasonable accommodation, according to accepted standards of professional
performance, and without posing a significant health and safety risk to others? If yes, on a separate sheet, please describe the essential function(s) and state the reason why
you may not be able to safely perform it.
7. Voluntarily or involuntarily, have any of the following ever been, or are currently being, denied, revoked, suspended, relinquished, withdrawn, reduced, limited, placed on
probation, not renewed, or currently pending/under investigation?
Medical/Psychology license in any state
Other professional registration/license
DEA Certificate of registration
Academic appointment
Membership on any hospital medical staff
Clinical privileges, prerogatives/rights on any medical staff
Board Certification
Any other type of professional sanction
8. Have you been subject to any disciplinary action in medical school or a post-graduate training program, or in any health care organization or medical society, or is any such
action pending?
Yes
No
Yes
No
Yes
No
Yes
No
9. Has any monitoring requirement been imposed?
Yes
No
11. Have there been any, or are there any, misdemeanor or felony criminal convictions against you, or charges pending against you, including those under the Criminal
Control Act?
12. Are there any pending or completed administrative agency, government, or court cases, decisions or judgments involving allegations that you failed to comply with laws,
statutes, regulations, or other legal requirements that may be applicable to the practice of your profession or to your rendition of service to patients?
Yes
No
Yes
No
13. Are there any prior or pending government agency or third party payer proceedings or litigation challenging or sanctioning your patient admission, treatment, discharge,
charging, collection, or utilization practices, including, but not limited to, Medicare Medicaid fraud and abuse proceedings or convictions?
Yes
NO
Candidate for House Staff (Re-)Appointment
My signature below indicates that I have provided complete and truthful information and answered the questions on this page completely and honestly. I give
permission for UCSF to validate any of the information provided above and in my CV, including, but not limited to, previous training, previous medical staff
appointments, and medical degree, at any time.
Do Re Mi
3/31/13
Candidate Signature
Date
Program Director
My signature below indicates that I have reviewed this candidate’s responses to the questions and recommend him/her for housestaff (re-)appointment.
Fa So La Ti
4/30/13
Program Director Signature
Date
Example of Yes Answer Explanations
In response to Question 3:
Are you aware of any malpractice claims currently pending/under investigation against you?
Yes, I was named in a malpractice claim in 2009. I was a PGY 1, Pediatrics resident, in the Emergency Room. A 6-year-old child slipped on a wet floor without a
yellow caution sign around in the Emergency Room and broke their leg. The patient’s mother decided to sue everyone involved in the Emergency Room. The
lawyer for the University of Michigan has informed me that my name will be removed from the claim, since I was a resident. I have not heard anything about the
case since being notified of the lawsuit.
In response to Question 11:
Have there been any, or are there any, misdemeanor or felony criminal convictions against you, or charges pending against you, including those under the
Criminal Control Act?
I received a DUI after attending my best friend’s wedding in the summer of 2002 in Arizona. Since the incident, I attended all court hearings and participated in
the required 20 hours of community service. I take full responsibility for my actions and have not driven a car after consuming any alcohol.
Do Re Mi
3/31/14
5
CALIFORNIA MEDICAL LICENSING REQUIREMENTS
All residents and clinical fellows must be in compliance with the rules and regulations of the California
Medical Board.
All trainees must have attended and obtained their medical degree from a California Medical Board
authorized medical school. To verify a medical school, please check the Medical Board website
(http://www.mbc.ca.gov/Applicants/Medical_Schools/Schools_Recognized.aspx).
Provider IDs will not be issued or will be shut off if license requirements are not met. Trainees should
applyfor their license or PTAL at least six months before starting their programs. License application and
renewal information can be found on the California Medical Board website
(http://www.mbc.ca.gov/Forms/#Licensees).
Acceptable Proof of Licensure
Licensed Trainees: usually PGY3 ACGME/ABMS trainees and above AND all non-ACGME trainees
• Printout of the license verification from the CA Medical Board website
(https://www.breeze.ca.gov/datamart/searchByName.do)
OR
• Copy of the current medical license card (the medical board certificate is not acceptable).
Unlicensed Trainees:
•
Postgraduate Training Registration Form (all unlicensed trainees)
• The Postgraduate Training Registration form is required for every trainee who is not licensed in
the state of California (usually PGY1 and PGY2 residents and anyone with a PTAL).
• This form is required for the GME appointment every year the trainee is unlicensed and should be
a copy of the form submitted the prior year if the trainee is continuing.
• All information should be completed on the form and it should be signed and dated by the trainee.
• Questions 8-15 are specific to the training that will be taking place at UCSF during the upcoming
academic year.
• This form must be submitted to the California Medical Board by the program coordinator prior to
the first year of training at UCSF. It should not be resubmitted to the Board every year.
•
Postgraduate Training Authorization Letter (PTAL) (unlicensed international medical
graduates)
• This is required for unlicensed international medical graduates (IMGs) training in ACGME
programs. Both the PTAL and the Postrgraduate Training Registration Form must be
submitted.
• The PTAL covers the IMG trainee during the period while he/she is working toward meeting
California licensure requirements.
• The PTAL is obtained from California Medical Board in a process similar to licensure.
Applicants should allow at least six months to complete the process.
• The PTAL is valid for a one-year period.
o To renew a PTAL, the trainee must resubmit forms L1A-L1F and a current CV to the
Medical Board. These documents must be submitted to the Medical Board prior to the
PTAL expiration date.
o If the trainee has been in an ACGME program for more than one year, he/she will
6
need to submit forms L3A/B and L4 to the Medical Board.
o If the IMG has previously submitted a L4 form, he/she does not need to resubmit this
form to the Medical Board unless he/she has changed programs.
STATE OF CALIFORNIA -- STATE AND CONSUMER SERVICES AGENCY
EDMUND G. BROWN JR., Governor
MEDICAL BOARD OF CALIFORNIA
LICENSING PROGRAM
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815
(800) 633-2322 (916) 263-2382 FAX (916) 263-2487
www.mbc.ca.gov
POSTGRADUATE TRAINING REGISTRATION FORM
To be completed by every medical graduate who is not licensed in California and who will commence an ACGME/RCPSC accredited postgraduate
training program in California. Please complete the information below and return this form to the Licensing Program of the Medical Board of
California at the above address. The filing of this form with the Board will fulfill the registration requirements specified by law.
1. NAME:
Last
First
2. Date of Birth:
Middle
3.
U.S. Social Security Number:
4. Home/Mailing Address:
5. Telephone Numbers:
(include area code)
Home
Work
6. Name and Address of Medical
School of Graduation:
7. Date Medical Degree Issued
8.
9. If no, list all other ACGME/RCPSC accredited postgraduate training programs in which you participated,
whether or not the program was completed or credit was granted.
Is this your first postgraduate
training year in the U.S.?
Yes
Cell
No
10.Name and address of facility where training is to be completed:
ACGME 10 digit program number
All information must be filled out on this page.
11. Name of the program director:
1.
12. Program director’s telephone number:
List categorical specialty area of training to be completed:
2. Beginning & Ending Dates of this program:
From:
To:
3.
I HEREBY DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT I HAVE READ THE LAWS,
AND THAT THE FOREGOING INFORMATION CONTAINED IN THIS DOCUMENT IS TRUE AND CORRECT.
Signature _________________________________________________________
Date _______________________
COMPLETION OF THIS FORM IS REQUIRED BY SECTIONS 2065 AND 2066
OF THE CALIFORNIA BUSINESS AND PROFESSIONS CODE.
07M-175A (Rev. 01/2011)
7
CV
•
•
Provide the most recent copy of the CV for new trainees only.
An ERAS application is acceptable for those who are starting training in the same year they applied,
but the actual CV is preferred.
RESPIRATOR CLEARANCE FORM
•
•
•
The Respirator Clearance form is required for new trainees only.
All questions must be answered.
Leave the assessment portion blank (bottom of page 2). It will be completed by UCSF Occupational
Health at GME New Resident and Fellow Orientation.
ABUSE REPORTING FORM
•
•
This form must be signed and dated by the trainee.
The abuse reporting form is for new trainees only.
HIPPA CONFIDENTIALITY STATEMENT
•
•
•
The HIPPA Confidentiality Statement is for new and continuing trainees.
Trainee signature is required.
The program coordinator should sign as “UCSF Representative.”
8
HEALTH STATEMENT (NEW TRAINEES)
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•
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All new trainees need to complete the two-page Health Statement (Pre-Placement Form and PPD
Reporting Form).
All sections of the form must be completed and then signed by a health care provider. Trainees
should complete as much as possible in UCMe then print the forms to take to his/her healthcare
provider for completion and signature. Once the forms are done, the trainee uploads them to UCMe
for submission to the program administrator.
All dates must be in MM/DD/YYYY format.
History of disease is not acceptable; trainees must show proof of vaccination or positive titers.
Immunizations:
o Measles (Rubeola): two doses or a positive titer
o Mumps: two doses or a positive titer
o Rubella (German Measles): one dose or a positive titer
o Varicella: two doses or a positive titer (history of chicken pox is NOT sufficient)
o TDAP (Tetanus, Diptheria, and Acellular Pertussis): one dose occurring in 2006 or later
o Hepatitis B: immunization is not required, but strongly recommended; if immunization is
being declined and/or a titer is negative, a declination form must be signed and included in the
packet
PPD Requirements:
• A health care provider must sign the PPD Reporting Form. Trainees cannot read their own PPDs.
• 10 mm or higher in duration is considered a positive PPD.
• Negative PPD History:
o One PPD done on March 1st or later (if starting June/July - if not, within three months of
start date) AND one within one year of start date
OR
o One negative QuantiFERON test within 12 months of start date. The date of the test must
be included on the PPD Reporting Form.
• Positive PPD History: Chest x-ray within one year of start date is required. A copy of the chest
x-ray interpretation must be included.
HEALTH STATEMENT (CONTINUING TRAINEES)
•
•
•
•
•
Continuing trainees with a negative PPD history are required to submit one PPD completed March 1st
or later if starting in June/July. The PPD must be within three months of the start date if the trainee is
starting off-cycle.
OGME will accept UCSF GME, UCSF Occupational Health, VA, SFGH, or other forms.
PPDs read by other trainees will not be accepted.
For a PPD positive history, trainees complete the Background Information section at the top of the
form and the bottom portion with the PPD positive history information.
If a continuing trainee has converted to PPD positive since his/her last appointment packet was
submitted, a copy of the chest x-ray interpretation done at the time of conversion must be included.
9
UNIVERSITY OF CALIFORNIA SAN FRANCISCO
SCHOOL OF MEDICINE, GRADUATE MEDICAL EDUCATION
2015–2016 HEALTH STATEMENT
FOR NEW RESIDENTS AND FELLOWS
Do
Re
First Name
Middle Name
Mi
Resident / Fellow
Last Name
Work Status (Please Circle One)
999-99-9999
Neonatology
01/01/1974
Female
Social Security Number
Program
Date of Birth
Gender
[email protected]
(123) 456-7890
Current Email
Current Phone Number
YOU MUST COMPLETE THESE FORMS IN FULL, REGARDLESS OF WHETHER YOU PROVIDE ADDITIONAL
DOCUMENTATION. ONLY COMPLETE FORMS WILL BE ACCEPTED.
•
The attached “Pre-Placement Health Statement” and “TB Skin Test Reporting Form” should be completed
by your primary care provider (or the Student Health Service of your medical school) prior to the start date
of your appointment. Failure to comply will delay processing of your UCSF Resident/Clinical Fellowship
appointment.
•
A physical examination must be performed under the direction of a physician as a condition of employment in a
hospital. The individual to be employed should be free of symptoms that indicate the presence of an infectious
disease.
•
Immunity to rubella, measles, mumps, and varicella is required. The required screening tests and/or
vaccinations are identified on the attached “Pre-placement Health Statement for New Residents and Fellows.”
•
Although immunization for hepatitis B is not required, it is strongly recommended. If the hepatitis B vaccination
has not been acquired or if a positive titer result has not been obtained, then the attached declination form must be
For new trainees the Health Statement is two pages. Please
completed.
•
complete
all vaccinations
inPertussis
MM/DD/YYYY
format. Vaccination must have been
Immunization for Tetanus,
Diptheria,
and Acellular
(TDAP) is required.
obtained in 2006 or later.
•
Screening for Tuberculosis is also required. Both positive and negative PPD readings must be recorded in
millimeters.
o
For individuals with a history of negative TB skin tests, please do the following 1) provide the results from one
TB skin test within the last year, and 2) provide the results of a TB skin test completed after March 1, 2015 (for
June/July 2015 start dates – all others must have second test done within 3 months of start date). In lieu
of two PPD test results, you may provide one negative QuantiFERON test result within 12 months of start date.
o
For individuals with a positive TB skin test, a copy of the written interpretation of a chest x-ray taken within
12 months of start date.
•
SUPPORTING DOCUMENTATION OF VACCINATIONS IS NOT REQUIRED BUT MAY BE
REQUESTED BY THE OFFICE OF GME.
•
All documents submitted require the name of a health care provider, address, phone number, and licensing
information (this must be written legibly on the attached forms).
• ALL INFORMATION IS CONFIDENTIAL. It will be entered into a confidential, centralized, HIPAA-compliant
database for purposes of reducing risk of exposure to TB, vaccine-preventable diseases, and bloodborne pathogens.
Please return these completed forms to your Program Coordinator
10
UNIVERSITY OF CALIFORNIA SAN FRANCISCO
SCHOOL OF MEDICINE, GRADUATE MEDICAL EDUCATION
PRE-PLACEMENT HEALTH STATEMENT FOR NEW RESIDENTS AND FELLOWS
First Name
Do
Last Name
Mi
MEASLES (rubeola)
OR
Date: _____/_____/_____
Measles or
Social Security Number
01/10/1974
999-99-9999
MUMPS
1) 2 doses live measles
vaccine or 2 doses MMR
vaccine
Dose 1:
Date of Birth
2) Positive measles titer
1) 2 doses live
mumps vaccine or
MMR vaccine
Date: __10__/_10__/__2000_
Date: _____/_____/_____
MMR ?
Dose 1:
Mumps or
OR
Date: _____/_____/_____
Dose 2:
Dose 2:
MMR ?
RUBELLA (German measles)
1) 1 dose live rubella
vaccine or MMR
vaccine
OR
Date: _____/_____/_____
Dose 1:
Rubella or
•
•
Mumps or
Date: __10__/__10__/__2000_
MMR ?
Date: _____/_____/_____
Measles or
2) Positive mumps titer
MMR ?
VARICELLA (chicken pox)
2) Positive rubella titer
1) 2 doses live varicella
vaccine
Date: __10__/__10_/_2000__
Date: _____/_____/_____
MMR ?
OR
2) Positive varicella titer
Date: __10___/_10__/_2000__
Dose 1
Please complete all vaccinations in MM/DD/YYYY format.
History of disease is not
Date: _____/_____/_____
acceptable
proof of immunity.
Trainees can have vaccination OR positive
titer
for
Measles,
Mumps,
Rubella,
Dose 2
Varicella and Hepatitis B.
HEPATITIS •
B – Complete
section
below
Trainee one
MUST
have
ALL vaccinations listed on this page (Measles, Mumps, Rubella,
Varicella, Hepatitis B and TDAP).
2) Doses
of HEP
Vaccine with an 3)
Previous Infection
– Mustby
provide
1) Hepatitis B Surface
Ab Titer
• The
document
must
be Bsigned
original
signature
a health4)professional.
Vaccine contraindicated for
core antibody & surface antigen titers
OR
Date: _____/_____/_____
Pos.___ Neg. ___
OR
Date: _12__/___15__/_2000____
Dose 1
Date: ___1__/__15__/_2001____
Dose 2
Hep B core Ab titer
Date: _____/_____/_____
Pos.___ Neg. ___
medical reasons
Completed declination
form attached
Hep B surface antigen
Date: ___2__/__3___/2002_____
Dose 3
OR
Date: _____/_____/_____
Pos.___ Neg. ___
TDAP (Tetanus, Diptheria, and Acellular Pertussis)
1 dose of vaccine
Date: ___07_/_01_/_2007__
(must be 2006 or later)
FOR PROVIDER: I attest that all dates and immunizations listed above are correct and accurate. I have examined the above
named physician within the past 30 days and certify that he/she is in satisfactory physical health and is free from symptoms
indicating the presence of infectious disease (if applicable, a list of exceptions is attached).
Name
___Dr. Gregory House___________________
Signature
_____Dr. Gregory House________________________
Title
_____MD___________________________
License #
___123456789__________________________
Phone
_____(111) 111-11111____________________
Fax
_(888) 888-88888___________________________
Address
_______Princeton-Plainsboro Teaching Hospital, 7777 Medical Center Way Princeton, NJ ____________
Trainee should be prepared to provide supporting documentation if requested.
11
UNIVERSITY OF CALIFORNIA SAN FRANCISCO
SCHOOL OF MEDICINE, GRADUATE MEDICAL EDUCATION
NEW RESIDENTS AND FELLOWS PPD REPORTING FORM
First Name
Last Name
Date of Birth
Social Security Number
Do
Mi
01/01/1974
999-99-9999
SIGN AND SYMPTOM REVIEW
Please fill out the following questions and have your provider fill out the questions related to PPD history below.
Have you ever had any of the following symptoms for more than three weeks at a time? (Please check ALL appropriate boxes)
Excessive sweating at night
Yes
No
Coughing up blood
Yes
No
For NEW
trainees:
Excessive weight loss
Yes
No
Hoarseness
Yes
No
If NEGATIVE PPDYes
history:No
Persistent coughing
Persistent fever
Yes
No
Excessive fatigue
Yes
No
• Two PPDs:
Completed
after
March
(foryour
June/July
date whether
– all others
If you have any of theoabove
symptoms, you
should
meet1with
provider tostart
determine
a chestmust
x-rayhave
is indicated. If a
chest
x-ray
is
indicated,
please
attach
documentation.
second test done within 3 months of start date).
One
within the last year.
Have you ever receivedoBCG
vaccine?
Yes
No
Year of most recent
BCG1_____________
Country __________________
• OR
Negative QuantiFERON.
Don’t Know
If POSITIVE PPD history:
• Chest X-Ray within with-in one year of start date.
Recent TB Skin Test (March 1, 2014 or later for June/July 2014
Prior TB Skin Test (within two years of start date)
• start
Need
to within
provide
copy
of the Chest X-Ray interpretation.
start dates; for other
dates,
3 months
of start)
PPD NEGATIVE HISTORY In lieu of 2 PPDs, 1 negative QuantiFERON test result within 12 months of start date may be submitted.
Date Applied:
03 /01//2014
Date Applied:
07 / 22 /2013
Date Read:
03 /03 /2014
Date Read:
07 / 25 /2013
mm Reading:
0 mm
mm Reading:
0
mm
PPD POSITIVE HISTORY
Year of TB skin test conversion ___________
mm Reading ____________
CHEST X-RAY REQUIRED: Please attach copy of chest
x-ray interpretation. X-ray must be done within 12 months
of start date.
INH / Other Therapy:
Date of last Chest X-Ray:
/
INH Therapy Taken:
Yes
No
Length of Treatment: _________months
/
Other Therapy:
X-Ray Results:
Normal
Abnormal
Yes
No
Length of Treatment: _________months
FOR PROVIDER: I attest that all dates and information listed above are correct and accurate.
Name
Dr. Gregory House
Signature
Dr. Gregory House
Title
MD
License #
123456789
Phone
(111) 111-11111
Fax
(888) 888-88888
Address
_____ Princeton-Plainsboro Teaching Hospital, 7777 Medical Center Way Princeton, NJ
12
UCSF COMMUNICABLE DISEASE PREVENTION PROGRAM
Employee Fact Sheet
OCCUPATIONAL EXPOSURE TO HEPATITIS B VIRUS (HBV)
HEPATITIS B: Hepatitis B is a viral infection of the liver caused by Hepatitis B virus (HBV). About 1.25 million people in
the U.S. have chronic Hepatitis B virus infection. Each year approximately 300,000 new infections are reported to the
Center for Disease Control. Most people who become infected with Hepatitis B recover completely, but 5 to I0% will
become chronic carriers of the virus. Although many chronic carriers do not have symptoms of the disease, they are
capable of transmitting the virus to other persons, primarily through blood exposures or sexual contact. Each year 4,000
to 5,000 persons die from chronic Hepatitis B.
OCCUPATIONAL EXPOSURE: In the hospital and university setting, health care workers with direct patient contact,
laboratory workers and researchers with blood or body fluid contact are at increased risk for acquiring the Hepatitis B
virus. An unvaccinated individual who receives an accidental blood or body fluid exposure from an infected source has a
40% chance of becoming infected with Hepatitis B. Each year in the U.S., more than 9,000 health care workers contract
Hepatitis B, and of those, 300 will die of liver-related disease.
VACCINATION: Becoming infected with Hepatitis B is preventable. The Hepatitis B vaccine, a synthetic vaccine made
This document
is workers
ONLY submitted
if
from a yeast base, is currently being offered
to health care
and other exposed
staff at UCSF at no cost to the
the
Hepatitis
B
vaccination
was
not
employee. Full immunization requires completion of a series of three vaccinations given over a six-month period. Eighty to
OR if antibodies
the trainee
doesprotect
NOTthem from getting Hepatitis B. There is
90% of healthy people who receive theacquired
vaccine develop
which
no evidence that the vaccine has ever have
caused
At this time,
no one knows how long the immunity produced by
a Hepatitis
positive B.
Hepatitis
B titer.
the vaccine will last and the need for additional vaccinations has not been determined. Health care workers who are
immunocompromised or on dialysis might require increased doses of vaccine in order to convert to positive antibodies.
The incidence of side effects is very low. A few people experience tenderness and redness at the injection site. A low
grade fever may occur. Rash, nausea, joint pain and mild fatigue have also been reported.
TREATMENT OF EXPOSURE: If the individual has received the Hepatitis B vaccine and has documented antibodies to
HBV, no further treatment is necessary at the time of exposure. However, someone who is not protected by the vaccine
and does not have antibodies to HBV, needs to receive HBIG (Hepatitis B Immunoglobulin) as soon as possible after the
exposure. These persons are also encouraged to receive the Hepatitis B vaccine at this time.
UCSF has a 24-hour EXPOSURE HOTLINE for anyone who has a blood or body fluid exposure. Anyone with an
exposure at Parnassus should call 415-353-7842 (STIC). If you have any questions about Hepatitis B or the
Hepatitis B vaccine, call Employee and Occupational Health Services at (415) 885-7580.
Please sign and return this form IF YOU HAVE NOT RECEIVED THE HEPATITIS B VACCINE AND
CHOOSE NOT TO BE VACCINATED.
HEPATITIS B VACCINATION DECLINATION
I understand that due to my occupational exposure to blood or other potentially infectious materials, I
may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be
vaccinated with Hepatitis B vaccine at no charge to myself. However, I decline Hepatitis B vaccination at
this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a
serious disease. If in the future I continue to have occupational exposure to blood or other potentially
infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination
series at no charge to me.
Signature
Do Re Mi
Date
4/14/14
Full Name
Do Re Mi
Social Security Number
999-99-9999
13
COMPETENCIES or PRIVILEGES and Non-ACGME Fellows
Every trainee must have either competencies or privileges.
Competencies
•
•
•
•
•
•
•
Competencies are a Joint Commission requirement for ACGME/ABMS trainees and non-ACGME
fellows with an exception to the concurrent clinical instructor without salary appointment and
privileges.
Competencies are a list of procedures determined by the program director, that a trainee may do
without direct supervision on the first day of that year of training.
Competencies are uploaded to each trainee’s file in UCMe by the program administrator.
To request or edit the competencies for a program or to create new competencies, contact the Office
GME.
Trainees should not cross things out or add procedures.
All competencies must be submitted annually signed and dated by BOTH the trainee and the program
director.
Central Venous Line Competencies
o Trainees must submit separate central venous line form in order to be granted the competency
of inserting and removing central venous line catheters. This form must be submitted
annually.
o The online training module can be found on the UCSF Learning Center.
o Once the program director believes the trainee has fulfilled the requirements, the program
coordinator has the program director and trainee sign the competency form and then submits
it to OGME.
o The program director must initial next to the approved competencies. Please leave all
unapproved competencies blank.
o This form must be hand-delivered to OGME and have wet signatures and dates from
both the trainee and program director.
o If a trainee has been deemed competent in a prior program, the program director of that
program can attest to the current program director that the trainee is competent. The trainee
must still complete the online module and submit the form to OGME.
Non-ACGME/Non-ABMS Clinical Fellows
Non-ACGME/non-ABMS fellows are required to have:
o Clinical fellow appointment (GME);
o Clinical instructor without salary appointment (Academic Affairs)
 Include proof in GME appointment packet (i.e. printout from Advance, Chair’s letter,
email from HR, screenshot from OLPPS, etc.); and
o Faculty privileges (Medical Staff Office) at all sites in which the trainee will rotate.
• These must be in place prior to the start date or the trainee will be unable to work.
14
Non-ACGME Exception
•
•
•
•
Exceptions may be requested from OGME to the concurrent faculty appointment and privileges for
those trainees who will function and be supervised like ACGME/ABMS trainees.
Trainees who are on a J-1 visa require an exception from OGME to the concurrent faculty
appointment and privileges.
When requesting an exception to the faculty appointment and privilege requirement, include an
exception letter from the program director as well as signed competencies in the appointment packet.
Those granted an exception will have to submit competencies instead.
Sample Non-ACGME Exception Letter
To Whom It May Concern,
XXX, MD will be a non-ACGME fellow in the Department of XXX and should be exempt from the
credentialing process because he will function as a trainee and his/her clinical work will be supervised by an
attending.
The fellow will adhere to all requirements and restrictions of his ECFMG J1 visa, as well as competencies
approved by his training program director, XXX, MD.
Sincerely,
XXXX
Program Director
XXX
Trainee
15
VISA
•
•
•
Visa documentation must be submitted as applicable through UCMe.
Please provide a copy of the DS 2019 for J-1 visas and form I 797 for H-1B visas in the appointment
packet. The approval dates on the form must cover the dates of the appointment.
Do not submit copies of driver’s licenses or SSN cards in OGME appointment packets.
ECFMG CERTIFICATE
•
•
A copy of the ECFMG certificate is required for all international medical school graduates (except
graduates from Canadian medical schools).
This certificate must be uploaded to E*Value (Training Tab), appropriate E*Value fields completed,
and submitted in the appointment packet.
16
E*VALUE ENTRY
General Requirements for E*Value
E*Value entry must be completed prior to submitting the appointment packet through UCMe to OGME. Do
not submit any E*Value documentation in the packet (i.e. screen shots). Biographic data may be entered
manually for each individual trainee or for multiple trainees via the annual ERAS data upload. OGME
facilitates the ERAS data import into E*Value in March after the Main Residency Match in March. OGME
will send an email to residency program administrators with details on how to complete this process. Please
note, the ERAS upload does not account for all data fields and program administrators will need to review
each profile as well as enter any additional information.
All fields on the E*Value checklist are required unless otherwise noted. Missing fields will delay
appointment approval.
New Trainees in E*Value
Even though a trainee may be considered new to UCSF GME, he/she may already have a profile in E*Value.
For example, if he/she was a UCSF medical student; visited a UCSF training program as short-term visitor;
or was a trainee at another institution. It is important to not create duplicate profiles in E*Value. Profiles of
trainees must be searched in the institution list and must include inactive users. Please account for name
changes, misspelled names, and other variables that may cause a profile search to return no users. Continuing
trainees will already have a profile in E*Value. If you discover you inadvertently created a duplicate
account, please notify [email protected]
To check if a trainee exists in E*Value:
1. Log into the incoming program of the trainee for the upcoming appointment season.
2. Under Profile Manager, select “Profiles,” then select Biographic Data.
3. Once in Biographic Data choose Fill list from… “Your Institution.” Don’t forget to check the
box “Return Inactive Users.” Enter the trainee’s last name.
4. If the trainee does not appear in the search, repeat step 3, with name changes or misspelled
names. If the trainee still does not appear in the search, then create a new profile. Click “Add
New User” and enter the trainee information in the required fields on the Biographic Data Tab
and hit “SAVE.
5. If the trainee does appear in the search, the program coordinator will need to request a Home
Program change through E*Value or by emailing the GME E*Value Help
Desk [email protected]
17
REQUIRED E*VALUE FIELDS FOR TRAINEES
Biographic Tab




















Home Program
Legal First Name
Legal Middle Name (if applicable)
Legal Last Name
Preferred First Name
Preferred Middle Name (if applicable)
Preferred Last Name
Credentials
Employee ID
National Provider Identifier (NPI)
Social Security Number
Gender
Date of Birth
Citizenship Country
Visa Type (if applicable)
Visa Expiration Date (if applicable)
Race/Ethnicity
Email Address
Status
Rank
Roles, Groups, and Specialties Tab
 Role
Training and Education
 Enter medical school and all subsequent training and employment
 ECFMG Certificate (for international medical graduates only)
 ECFMG Dates and Number (for international medical graduates only)
Exam Scores Tab (Page)
 Exam Scores (new, unlicensed trainees only)
Contact Tab (Page)
 Home Contact Address and Home Phone
 Organization Contact Address and Phone Pager
 Mailstop
Miscellaneous Tab (Page)





DEA Registration Number
License Expiration Date
License Number
Permanent/Emergency Email
Date UCSF GME Training Commenced (new trainees only)
18
BIOGRAPHIC TAB
 Home Program: “Home Program” designates the program to which a trainee is participating in at
UCSF. The home program for a trainee can be found in the Biographic Tab, in the top left corner of
the page under the words “Home Program.” The “Home Program” much match the program listed in
the Training and Education tab for the current academic year.
o Continuing Trainees and Home Program:
• If a continuing trainee is staying in the same program --- no action is required for the
program coordinator. OGME will handle the functionality of promoting the trainee’s rank
for the upcoming appointment period.
• If a continuing trainee is moving from one program to another --- home program should
be changed before the packet is submitted to OGME (this does not affect evaluations or
anything else in E*Value).
o Home Program Changes:
1. Log into the incoming program of the trainee for the upcoming appointment season.
2. Under Profile Manager, select “Profiles,” then select Biographic Data.
3. Once in Biographic Data choose Fill list from… “Your Institution.” Don’t forget to check
the box “Return Inactive Users.” Enter in the last name of the trainee.
4. If the trainee does appear in the search,
5. Save the trainee with the status of “Pre-Active” and select the upcoming PGY rank.
6. On the top left hand side of the page under “Home Program” click on the link for the
home program.
7. Fill out the request for the Home Program Change. This will send an email to the E*Value
administer of the trainee’s other home program. The E*Value administer will make the
home program change.
8. If the home program request doesn’t occur within a few days, the program coordinator can
request the home program request by email to E*Value Help Desk
@ [email protected]
 Legal First Name
 Legal Middle Name (if applicable)
 Legal Last Name
 Preferred First Name
 Preferred Middle Name (if applicable)
 Preferred Last Name
 Credentials: Example, DO, MBBS, MD, PhD
 Employee ID: The UCSF employee ID is automatically generated in E*Value. If you have the
employee ID, do not enter it into E*Value. It will be populated once you enter all other required
information and click “Save.” If a FUZZY MATCH occurs email the GME E*Value Help Desk
([email protected]) before proceeding.
 National Provider Identifier (NPI)
 Social Security Number: Enter using the format ###-##-#### For international trainees who have
no SSN, it is possible to initially create the file with a SSN of 000-00-0000. Put this information in
the notes session. When the trainee obtains their actual SSN please contact the GME E*Value Help
Desk ([email protected]) to update the SSN. Do NOT email the SSN for security
reasons, this information must be provided to OGME by phone.
 Gender
 Date of Birth Enter using the format MM/DD/YYYY
 Citizenship Country
 Visa Type: Required only for trainees with a visa.
 Visa Expiration Date: Required only for trainees with a visa.
19
 Race/Ethnicity: Only enter race/ethnicity self-identified by the trainee. Do not guess. If the
Race/Ethnicity of your trainee is not self-identified, please list it as “No Response/Undeclared.”
 Email Address: Must be a UCSF email address. However, if the UCSF email address has not been
created at the time of E*Value entry, another email address may be used, but it must be changed to a
UCSF email address as soon as one has been assigned.
 Status: For new trainees select “Pre-Active.” OGME will change this to Active on the start date. For
continuing trainees status should remain “Active.”
 Rank: For new trainees select the rank for the upcoming appointment period. For continuing trainees
don’t change the trainee’s rank, OGME will process the promotion on the start date of the upcoming
academic year.
NOTE: Birthplace: Birthplace must not be entered because this is known to cause errors in creating the
Employee ID.
20
ROLES, GROUPS, AND SPECIALTIES TAB
 Role: Trainee
John TestResident
21
TRAINING AND EDUCATION TAB
The Training and Education Tab may only be edited by an administrator for the trainee’s home program.
 Enter medical school and all subsequent training and employment
o The following information must be accounted for in the Training and Education Tab:
 All gaps of more than 90 days between medical school and the start of the PGY1
training year must be accounted for.
 Medical/Osteopathic School
• Select the trainee’s medical/osteopathic school from the drop down list of
medical or osteopathic programs.
• For international medical schools, select “Foreign Medical School” and write
the name and location (city and country) of the school in the notes section.
• If the exact start and end dates of the trainee’s medical school are unknown,
you may enter the first and last date of the month as the start and end dates.
 Postgraduate Training
• All postgraduate training years must be entered as separate training lines.
• All PGY years must be listed with a maximum of 365/366 days per training
line.
• Select the residency and/or fellowship training in the drop down menu under
each state (i.e. CA or NY). Upon selection of state, choose the specialty of the
training, then the name of the hospital of training.
• All breaks between training years should be listed separately:
o For trainees with a 10-day break between their PGY1 and PGY2 years,
enter the training line as PGY1 from 6/21/20XX to 6/20/20XX and
“Not Assigned” from 6/21/20XX to 6/30/20XX (with a description of
“Break” in the 10-day period).
 Research
• All research experience must be listed.
o If a trainee has done research a multiple institutions this can be grouped
together. Please put in the notes section the dates and locations of each
research experience.
 Previous Employment
• All previous employment must be listed, If the trainee has numerous
employers over a large time period, these may be grouped together, Please put
the in the notes section the dates and locations of employment experience.
o Make sure the training and education “appointment line” is correct for each appointment year.
It’s the appointment line in the training and education tab that determines where the trainees
show up on all the reports in the system for evaluations, Medicare reimbursement, duty hours
etc.
o To check for errors in the Training and Education Tab, click on “Check for Errors,” which is
located above the “Action” column. This report will show if there are gaps in
training/employment, PGY years are out of order, medical schools are missing, etc.
o If any programs (i.e. medical school or training program) cannot be found in the drop down
list please email [email protected]
22
Medical School Training
Research
Residency Training
Break in Training
Check for Errors Link
Fellowship Training
 ECFMG Certificate (if applicable): Upload the ECFMG Certificate if the trainee is an international
medical graduate. After uploading the EFMG certificate, verify that the certificate is loaded. If the
document did not load, email [email protected]
 ECFMG Dates and Number (if applicable)
23
EXAM SCORES TAB
 Exam Scores: Exam scores are required for new, unlicensed trainees only. Only the date and
pass/fail are required, however the scores may be entered for the program’s records.
USMLE Scores
COMLEX Scores
24
CONTACT TAB
 Home Contact Address and Home Phone For new trainees, enter a current home address. OGME
will use this address to run the background check. Two weeks prior to start date please change this
information to the trainee’s Bay Area address. For continuing trainees, verify that the home address
and home phone numbers are current for the trainee.
 Organization Contact Address and Phone Include the UCSF mailbox number in last 4 digits of the
Zip.
 Pager: Enter UCSF pager as (###) ###-####.
 Mailstop: Enter UCSF mailbox #. For trainees at training at SFGH or VA this field may be left
blank.
John TestResident
25
MISCELLANEOUS TAB
 DEA Registration Number (1): This is required for all licensed trainees.
 License Expiration Date and License Number (2): Expiration dates must be entered in the
MM/DD/YYYY format. For licensed trainees, the license number must include both the alpha and
numeric characters of the license number (i.e. A12345 or G12345). For trainees with a PTAL, put
“PTAL” and list the expiration date of the PTAL (i.e. 06/30/2015). For unlicensed trainees working
toward licensure, enter “L3” and the expiration date is the last day the trainee can work without a
license (usually the last day of the PGY2 year).
 Permanent/Emergency Email (3): List a personal, non-UCSF email. Please note, this email address
will only be used in case of an emergency when the UCSF email system is down.
 Date UCSF GME Training Commenced (4): This is required for new trainees only. This must
match the start date of the first UCSF GME program the trainee participates in.
1
2
3/4
26