1. science
2. medicine
3. pediatrics

Graduate Medical Education
Rutgers, The State University of New Jersey
185 South Orange Ave, MSB, C594
Newark, NJ 07101
p. 973-972-
f. 973-972-2229
Rotator General Information
Housestaff from other training programs interested in a clinical rotation in one of our programs located at the Rutgers New
Jersey Medical School- Newark campus are welcome to apply. Completed applications are reviewed and approval is
granted on a case-by-case basis provided trainees meet specific qualifications and entry requirements. Generally,
trainees will be considered if they:
1) are in good standing in an ACGME-accredited program
2) obtain approval and support to rotate from a Rutgers Program Director
3) complete and submit all rotator documentation and properly enroll prior to start date
If you wish to apply for a rotation in one of our programs please note the timeline and information requirements below.
•
•
Contact the program coordinator of the Rutgers program you wish to complete a rotation to determine if the
program is currently accepting rotators. The recommended time to contact a program is at least three months
prior to the start of the rotation (see Program Coordinator Contact List).
Complete and submit the following documents to the respective Rutgers program coordinator at least two (2)
months prior to the expected rotation start date:
9
9
9
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
•
•
•
•
Rotator Application for Residency/Fellowship Rotation
Rotator Medical Requirements (Health Clearance Form)
Rotator Documentation:
Letter of support indicating housestaff in good standing from home institution (indicating rotation dates)
Letter of approval from Rutgers Program Director (indicating rotation dates)
Current Curriculum Vitae (CV)
Copy of valid/unexpired picture identification (driver’s license, passport, etc.)
Copies of BLS, ACLS, PALS valid certification through the rotation timeframe (please see Life Support
Certification Requirements for specific information by program)
Malpractice insurance coverage verification from home institution (must indicate coverage through rotation
timeframe)
Copy of medical license, DEA, or training permit from trainees Board of Medical Examiner’s Office FROM
ROTATOR CURRENT TRAINING STATE
US Medical Graduates-Copy of Medical School Diploma
Foreign Medical Graduates- Copy of ECFMG certificate/Fifth Pathway Certificate
Rutgers Confidentiality Statement
Approximately one month prior to your rotation you will receive notification from the GME Office indicating if your
application was approved. You will be provided with instructions for completing the mandatory online training and
will be enrolled in CLASSROOM clinical systems training. FAILURE TO COMPLETE ONLINE or CLASSROOM
TRAINING BEFORE YOUR START DATE WILL FORFEIT ROTATION APPROVAL.
You must provide all online training certificates no less than ONE WEEK prior to start date (may be faxed to (973)
972-2229.
You must present to the GME Office your first day (or several prior if your start date is on a holiday or weekend as
the GME office may be closed); obtain your medical record dictation number, clinical systems passcodes, Rutgers
identification card and parking.
It is the rotator’s responsibility to make arrangements for housing and transportation as necessary.
Please contact the Graduate Medical Education Office if you have any questions (973) 972-6049 regarding this process.
Updated 3/25/2015
Graduate Medical Education
Rutgers, The State University of New Jersey
185 South Orange Ave, MSB, C594
Newark, NJ 07101
p. 973-972-6049
f. 973-972-2229
Rutgers NJMS Newark-Program Coordinator Contact List
Program
First Name
Allergy & Immunology (ACGME Accredited) Michelle
Last Name
Telephone
Jimenez
973-972-6111
Anesthesiology (ACGME Accredited)
Lisa
Chappelle
973-972-0470
Cardiology (ACGME Accredited)
Jacquie
Johnson
973-972-5291
Child Neurology (ACGME Accredited)
Cari
Stephens
973-972-5209
Child Psychiatry (ACGME Accredited)
Rivas
Jackie
973-972-4670
Dermatology (ACGME Accredited)
Linda
Hesselbirg
973-972-6255
Diagnostic-Radiology (ACGME Accredited) Maria
Lopez
973-972-5188
Hughes
973-972-9261
Endocrinology, Diabetes, Metabolism (ACGME Accredited) Marsha
Taylor
973-972-3479
Gastroenterology (ACGME Accredited) Jackie
O'Bryant
973-972-5252
201-996-2570
Emergency Medicine (ACGME Accredited)
Eleanor
Geriatrics (ACGME Accredited)
Neena
Arora
Hepatology (Non-Accredited)
Jackie
O'Bryant
973-972-5252
Wade
973-972-7837
Infectious Diseases (ACGME Accredited) Lisa
Internal Medicine (ACGME Accredited) Jeannine
Mansfield
973-972-6056
Internal Medicine-Pediatrics (ACGME Accredited) Jeannine
Mansfield
973-972-6015
Interventional Cardiology (ACGME Accredited) Jacquie
Johnson
973-972-5291
Nephrology (ACGME Accredited)
Vivian
Romero
973-972-4100
Neurological Surgery (ACGME Accredited)
LaDawn
McClamb
973-972-1164
Neurology (ACGME Accredited)
Cari
Stephens
973-972-5209
Neurology-Multiple Sclerosis (Non-Accredited) Cari
Neurology-Vascular (ACGME Accredited)
Cari
Neurosurgery Endovascular Neuroradiology (Non-Accredited) LaDa
OB/GYN (ACGME Accredited)
wn
Gloria
OB/GYN-Maternal Fetal Medicine (Non-Accredited) Gloria
OB/GYN-Reproductive Endocrinology (Non-Accredited) Gloria
Stephens
973-972-5209
Stephens
973-972-5209
McClamb
973-972-1164
Shelton
973-972-5266
Shelton
973-972-5266
Shelton
973-972-5266
Ophthalmology (ACGME Accredited)
Denise
Durant
973-972-2063
Oral Maxillofacial Surgery (Accredited)
Kisha
Wesley
973-972-3126
Orthopedics (ACGME Accredited)
Marie
Birthwright
973-972-3860
Orthopedics-Hand Surgery (ACGME Accredited) Marie
Birthwright
973-972-3860
Orthopedics-Musculoskeletal Oncology (ACGME Accredited) Marie
Birthwright
973-972-3860
Otolaryngology (ACGME Accredited) Fa
Pathology (ACGME Accredited)
ye
Maria
Wiggins
973-972-4588
Caraballo
973-972-5722
Pediatrics (ACGME Accredited)
Odemaris Valencia
973-972-0740
Pediatrics-Infectious Disease (ACGME Accredited)
Odemaris
Valencia
973-972-0740
Plastic Surgery (ACGME Accredited)
Amy
Stolar
973-972-8092
PM&R (ACGME Accredited)
Doreen
Muhammad
973-972-3606
Muhammad
973-972-3606
PM&R-Musculoskeletal Rehabilitation Medicine (Non-Accredited) Doreen
PM&R-Pediatrics (ACGME Accredited) Doreen
PM&R-Spinal Cord Injury (ACGME Accredited)
Muhammad
973-972-3606
Doreen
Muhammad
973-972-3606
Muhammad
973-972-3606
Joyce
Pettus
973-972-5088
Battle
973-972-0609
Rivas
973-972-4670
Jimenez
973-972-6111
PM&R-Traumatic Brain Injury Medicine (Non-Accredited) Doreen
Podiatry (Accredited)
Preventive Medicine (ACGME Accredited) Kellee
Psychiatry (ACGME Accredited)
Jackie
Pulmonary Critical Care (ACGME Accredited) Michelle
Surgery (ACGME Accredited)
Daphne
Woods
973-972-6601
Surgical Critical Care-Trauma (ACGME Accredited)
Jennifer
Zabala
973-972-4900
Urology (ACGME Accredited) Shaniqua
Mitchell
973-972-4418
Vascular Surgery (ACGME Accredited) Daphne
Woods
973-972-6601
Updated 3/25/2015
Graduate Medical Education
Rutgers, The State University of New Jersey
185 South Orange Ave, MSB, C594
Newark, NJ 07101
p. 973-972-6049
f. 973-972-2229
Rutgers NJMS Newark-Rotator Application Documentation Checklist
Applicant, please complete and submit the following documents to the respective Rutgers program coordinator.
A COMPLETE file must be submitted to your Rutgers Program Coordinator at least two (2) months
prior to the expected rotation start date!
No.
1
2
3
4
5
6
7
8
9
10
11
12
Documents
Rotator Application for Residency/Fellowship Rotation
Rotator Medical Requirements (Health Clearance Form)
Rotator Documentation:
Letter of approval and support from home institution indicating housestaff is
in good standing and the rotation timeframe
Letter of approval and support from Rutgers Program Director (indicating
rotation timeframe)
Current Curriculum Vitae (CV)
Copy of valid/unexpired picture identification (driver’s license, passport, etc.)
Copies of BLS, ACLS, PALS valid certification through the rotation timeframe
(please see Life Support Certification Requirements for specific information
by program)
Malpractice insurance coverage verification from home institution (must
indicate coverage through rotation timeframe)
Copy of medical license & DEA, training permit, state registration from
trainee’s Board of Medical Examiner’s Office (ROTATOR CURRENT
TRAINING STATE)
US Medical Graduates-Copy of Medical School Diploma
Foreign Medical Graduates:
Copy of ECFMG certificate/Fifth Pathway Certificate
Rutgers Confidentiality Statement
Submitted
Updated 3/25/2015
p. 973-972-6049
f. 973-972-2229
Graduate Medical Education
Rutgers, The State University of New Jersey
185 South Orange Ave, MSB, C594
Newark, NJ 07101
Rotator Application for Residency/Fellowship Rotation-Part 1
Please print or type. All information must be complete.
Personal Information
Full Name:
Last
Sex:
Male
First
Female (Circle One)
Middle
Date of Birth: _____________________
Home Address(Current):
Street Address
Phone:
(
)
Emergency
Contact Name:
Pager:
City
(
)
State
Zip Code
Email: ________________________
Emergency
Contact Phone: _(_____)_______________________
___________________________________
Emergency
Contact Address:
Street Address
City
State
ZIP Code
Employment Status
Social Security Number: ______________________
Citizenship: (Circle One)
Current Visa
J1
Status:
1) US (By Birth)
NPI Number: ________________________
2) US-Naturalized
H1B EA Other (Circle One)
3) Other:__________________
Fit Tested for N95 Respirator: Yes
No (Circle One)
Licensure/Training Permit
Are you licensed?
Yes
No (Circle One)
License
Number:
State:
Expiration:
mm/dd/yy
License Type:
Medical
Dental
Do you hold a training permit?
Yes
Other
(Circle One)
No (Circle One)
State: ___
Podiatry
__________
Expiration: ______________ mm/dd/yy
Education
Medical School:
Location:
Degree:
From (mm/dd/yy)
________________
To (mm/dd/yy)
________________
Internship:
Hospital Name and Location:
From (mm/dd/yy)
________________
To (mm/dd/yy)
________________
Residency (List name):
Hospital Name and Location:
From (mm/dd/yy)
________________
To (mm/dd/yy)
________________
Fellowship (List name):
Hospital Name and Location:
From (mm/dd/yy)
________________
To (mm/dd/yy)
________________
Updated 3/25/15
Graduate Medical Education
Rutgers, The State University of New Jersey
185 South Orange Ave, MSB, C594
Newark, NJ 07101
p. 973-972-6049
f. 973-972-2229
Rotator Application for Residency/Fellowship Rotation-Part 2
Rotator Last Name: ___________________________ Rotator First Name: __________________________ Middle Initial ________
Social Security Number: __________________________ Employer/Institution: __________________________________________
Current Program
Program:
PGY Level:
State:
Residency Year:
ACGME Accredited?
Yes
No (Circle One)
RUTGERS Program
Rotation To : __________________________ (mm/dd/yyyy)
Rotation From : _________________________ (mm/dd/yyyy)
Program:
Describe Rotation Experience (e.g program: anesthesia rotation: pain management):
I attest that the information contained in this application is true and accurate. The documents presented to evaluate my
application are authentic/copies of documents issued by legitimate source entities.
_________________________________________
Applicant Signature
Date
____
________________
The information for the applicant identified above is accurate as evidenced by your records. This applicant has satisfied
all employment and training requirements identified by your institution including:
• Primary source verification of medical school and other medical training (e.g. internship residency training).
• Received orientation training including preventing harassment and discrimination, radiation safety, patient safety,
infection control/influenza and environment of care.
• Cleared a criminal background check.
• Enrolled in your training program in accordance with your institution’s policies, accrediting, licensing, specialty
board, state and federal agencies and employment requirements as applicable.
_________________________________________________
Signature Program Director/Program Coordinator (Circle One)
____________________
Date
_________________________________________________
Print Name Program Director/Program Coordinator (Circle One)
____________________
Phone Number
Page 2 of 2
Updated 3/25/2015
Graduate Medical Education
Rutgers, The State University of New Jersey
185 South Orange Ave, MSB, C594
Newark, NJ 07101
p. 973-972-6049
f. 973-972-2229
Rotator Medical Requirements (Health Clearance Form)
Rotator Last Name: ___________________________ Rotator First Name: __________________________ Middle Initial ________
Social Security Number: __________________________ Employer/Institution: __________________________________________
Please attest that the following documentation for the above-named individual is on file with your institution:
1. An annual or the initial Health Assessment within the past twelve (12) months certifying fitness for duty for the
rotator’s work functions in a health care facility.
2. Record of Immunity by laboratory titers to rubella, rubeola, mumps and varicella. If laboratory titers are nonimmune, then record of full vaccination is required (at least 2 MMRs, Varivax series) unless there is a
documented medical contraindication to vaccination.
3. Documentation of laboratory testing for Hepatitis B (HB) Surface Antigen, HB Surface Antibody and HB Core
Antibody. Evidence of immunity by positive antibody titers to Hepatitis B or documentation that full Hepatitis B
vaccination has been received or proof of declination of Hepatitis B vaccine. If Rotator is Hepatitis B Surface
Antigen positive, the New Jersey Medical School Occupational Medicine Service (973-972-2900) must be
contacted regarding further evaluation prior to rotation at Rutgers-Newark.
4. Record of Tdap in adulthood or record of medical contraindication to Tdap vaccination.
5. Record of seasonal influenza vaccination or documentation of medical contraindication to influenza vaccination.
6. Record of annual TB skin test (or blood assay for TB) if negative. If positive, documentation of negative chest xray at initial evaluation and annual symptom survey. If chest x-ray revealed evidence of active TB, documentation
of appropriate medical treatment and annual symptom survey.
7. Medical clearance for respirator fit testing for N95 respirator or PAPR if needed.
Physician or Director of Occupational Health for the above-named institution or employer:
___________________________________________________
Print Name/Title
___________________________________________________
Signature
_____________________
Date
___________________________
Phone Number
Updated 3/25/2015
p. 973-972-6049
f. 973-972-2229
Graduate Medical Education
Rutgers, The State University of New Jersey
185 South Orange Ave, MSB, C594
Newark, NJ 07101
Life Support Certification Requirements
Program
Allergy & Immunology
BLS
ACLS
X
X
Anesthesiology X
X
Cardiology X
X
PALS
X
Child Neurology
X
X
Child Psychiatry
X
X
Dermatology X
Diagnostic-Radiology X
X
Emergency Medicine
X
X
Endocrinology, Diabetes, Metabolism
X
X
X
X
Gastroenterology X
Geriatric Medicine
X
Hepatology X
X
Infectious Disease
X
X
Internal Medicine
X
X
Internal Medicine/Pediatrics
X
X
Interventional Cardiology
X
X
X
X
Nephrology X
Neurological Surgery
X
X
X
X
X
X
Neurology-Vascular X
Neurosurgery Endovascular Neuroradiology
X
X
Neurology X
Neurology- Multiple Sclerosis
X
X
OB/GYN X
X
X
OB/Gyne- Maternal-Fetal Medicine
X
X
X
OB/Gyne- Reproductive Endocrinology
X
X
X
X
Ophthalmology X
Oral Maxillofacial Surgery
X
Orthopedics X
X
Orthopedics-Hand Surgery
X
X
Orthopedics-Musculoskeletal Oncology
X
X
Otolaryngology X
X
X
Pathology X
Pediatrics X
Pediatrics Infectious Disease
X
X
X
Plastic Surgery
X
PM&R
XX
X
PM&R-Musculoskeletal Rehabilitation Medicine
X
X
PM&R-Spinal Cord Injury
X
X
PM&R-Traumatic Brain Injury Medicine
X
X
Preventive Medicine
X
X
PM&R-Pediatric X
X
Podiatry X
X
Psychiatry X
X
Pulmonary Critical Care
X
X
X
X
Surgery X
Surgery Critical Care-Trauma
X
Urology X
Vascular Surgery
X
X
X
X
Updated 3/25/15
Confidentiality Statement
All patient Protected Health Information (PHI - which includes patient medical and financial information),
employee records, student records, financial and operating date of the Rutgers Biomedical and Health
Sciences, and any other information of a private or sensitive nature are considered confidential
information should not be read or discussed by any employee unless pertaining to his or her specific job
requirements.
Examples of inappropriate disclosures include:



Employees discussing or revealing PHI or other Confidential information to friends
or family members
Employees discussing or revealing PHI or other Confidential Information to other
employees without a legitimate need to know.
The disclosure of a patient's presence in the office, hospital, or other medical facility,
which may reveal the nature of the illness, without the patients consent, to an
unauthorized party without a legitimate need to know.
The unauthorized disclosure of PHI or other Confidential Information by employees can subject each
individual and the Rutgers Biomedical and Health Sciences to civil and criminal liability. Disclosure of
PHI or other Confidential Information to unauthorized persons, or unauthorized access to, or misuse,
theft, destruction, alteration, or sabotage of such Information, are grounds for immediate disciplinary
action up to and including termination.
Employee/Volunteers/Student Confidentiality Agreement
I hereby acknowledge, by my signature below, that I understand that PHI and Confidential information
and data to which I have knowledge and access in the course of my employment with the Rutgers
Biomedical and Health Sciences is to be kept confidential, and this confidentiality is a condition of my
employment. This information shall not be disclosed to anyone under any circumstances, except to the
extent necessary to fulfill my job requirements. I understand that my duty to maintain confidentiality
continues even after I am no longer employed. Further, upon termination with the Rutgers Biomedical
and Health Sciences I shall return to the University all Confidential Information.
I am familiar that the Rutgers Biomedical and Health Sciences has guidelines in place pertaining to the
use and disclosure of patient PHI and other Confidential Information. Approval should first he obtained
before any disclosure of PHI or other Confidential Information not addressed in the guidelines and
policies and procedures of the Rutgers Biomedical and Health Sciences is made. I also understand
that the unauthorized disclosure of patient PHI and other Confidential Information of the Rutgers
Biomedical and Health Sciences is grounds for disciplinary action, up to and including immediate
termination.
In the event of a breach of this agreement, the Rutgers Biomedical and Health Sciences may pursue
equitable relief.
The laws of the State of New Jersey shall govern this agreement.
Signature of Employee/Volunteer/Student
Print Name
Supervisor
Date