VERIFICATION OF GRADUATE MEDICAL EDUCATION & TRAINING Section I: Verification of training and performance during training (To be completed for EACH trainee) Trainee’s Full Name: DOB: NPI: Click here to enter text. Click here to enter text. Click here to enter text. Program Specialty or Subspecialty: Program: Date From/To: Click here to enter text. mm/dd/yyyy (Start) mm/dd/yyyy (End). ☐Preliminary – Residency Program: Date From/To: Click here to enter text. mm/dd/yyyy (Start) mm/dd/yyyy (End). ☐Core – Program: Date From/To: Click here to enter text. mm/dd/yyyy (Start) mm/dd/yyyy (End). ☐Fellowship – Training Program Accreditation: ACGME AOA ☐ ☐ ☐Other If marked please indicate accreditation type or list Click here to enter text. “other,” “none:” Program ID #: Click here to enter text. Did the above-named trainee successfully complete the training program which she/he entered? Yes No □ ☐ In addition to completion of full specialty training, completion of a transitional year or a planned preliminary year(s) would constitute completion of a program. (If NO, please provide an explanation in the Comments” section below or enclose a separate document.) “Additional Was the trainee subject to any of the following during training? Conditions or restrictions beyond those generally associated with the training regimen at your facility; No ☐Yes ☐ Involuntary leave of absence; Yes No ☐ ☐ Suspension; Yes No ☐ ☐ Non-promotion/non-renewal; Yes No ☐ ☐ Dismissal; or Yes No ☐ ☐ Resignation. Yes No ☐ ☐ (If YES to any of the above, please provide an explanation in the Comments” section below or “Additional enclose a separate document.)
VERIFICATION OF GRADUATE MEDICAL EDUCATION & TRAINING Section I: Verification of training and performance during training (To be completed for EACH trainee) Trainee’s Full Name: Click here to enter text. DOB: Click here to enter text. NPI: Click here to enter text. Program Specialty or Subspecialty: ☐Preliminary Program: Click here to enter text. Date From/To: mm/dd/yyyy (Start) – mm/dd/yyyy (End). ☐Core Residency Program: Click here to enter text. Date From/To: mm/dd/yyyy (Start) – mm/dd/yyyy (End). ☐Fellowship Program: Click here to enter text. Date From/To: mm/dd/yyyy (Start) – mm/dd/yyyy (End). Training Program Accreditation: ☐ ACGME ☐ AOA ☐Other If marked “other,” please indicate accreditation type or list “none:” Click here to enter text. Program ID #: Click here to enter text. Did the above-named trainee successfully complete the training program which she/he entered? □ Yes ☐ No In addition to completion of full specialty training, completion of a transitional year or a planned preliminary year(s) would constitute completion of a program. (If NO, please provide an explanation in the “Additional Comments” section below or enclose a separate document.) Was the trainee subject to any of the following during training? Conditions or restrictions beyond those generally associated with the training regimen at your facility; ☐Yes ☐ No Involuntary leave of absence; ☐ Yes ☐ No Suspension; ☐ Yes ☐ No Non-promotion/non-renewal; ☐ Yes ☐ No Dismissal; or ☐ Yes ☐ No Resignation. ☐ Yes ☐ No (If YES to any of the above, please provide an explanation in the “Additional Comments” section below or enclose a separate document.)