OFFICIAL CLEARANCE FORM Physician ID: ___________ Dr. , Department/Division of , has officially cleared with the following VAH, and University Hospital areas and is eligible to receive his/her Graduate Training Certificate and (if UHS funded) his/her final paycheck. NOTE: #1 CANNOT BE COMPLETED #1 THROUGH #1 ARE SIGNED OFF BY THE APPROPRIATE PERSONNEL. THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO 1. Program Director or Designee Signature & Date Comments 2. Library Personnel (Room 3.010) Signature & Date Comments 3. UT Police (Dental School Garage) Signature & Date Comments Returned - MARC/CTRC parking permit Paid $3 fee for lost MARC/CTRC parking permit (cash only) 4. Alumni Office Comments Fill out survey from link below and attach a copy for Copy of the review page is attached. clearance. 5. Institutional Review Board Program Coordinator Signature & Date Program Coordinator must submit a list of graduating residents/fellows to the IRB via () to ensure they are Copy of email from IRB is attached. not involved in active research projects. Attach IRB Response for clearance. 6. Office of International Services Signature & Date Comments Visa Holders Only (Med 331A between Holly Auditorium and Parking Garage A)
OFFICIAL CLEARANCE FORM Physician ID: ___________ Dr. , Department/Division of , has officially cleared with the following VAH, and University Hospital areas and is eligible to receive his/her Graduate Training Certificate and (if UHS funded) his/her final paycheck. NOTE: #1 CANNOT BE COMPLETED #1 THROUGH #1 ARE SIGNED OFF BY THE APPROPRIATE PERSONNEL. THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO 1. Program Director or Designee Signature & Date Comments 2. Library Personnel (Room 3.010) Signature & Date Comments 3. UT Police (Dental School Garage) Signature & Date Comments Returned - MARC/CTRC parking permit Paid $3 fee for lost MARC/CTRC parking permit (cash only) 4. Alumni Office Comments Fill out survey from link below and attach a copy for clearance. Copy of the review page is attached. 5. Institutional Review Board Program Coordinator Signature & Date Program Coordinator must submit a list of graduating residents/fellows to the IRB via () to ensure they are not involved in active research projects. Attach IRB Response for clearance. Copy of email from IRB is attached. 6. Office of International Services Signature & Date (Med 331A between Holly Auditorium and Parking Garage A) Comments Visa Holders Only