Request for Affiliation Agreement for Resident Rotation

Please complete this form to initiate an affiliation agreement for resident rotations to Virginia Mason from another facility or from Virginia Mason to another facility. The Graduate Medical Education Department will contact you to schedule a telephone intake appointment upon receipt of this information.

For Virginia Mason requestors, the requestor must be a Virginia Mason Residency Program Director, faculty or GME Director.
If another health care facility is requesting a rotation, requestor must be a GME Director or Residency Program Director for that facility.

Name of Virginia Mason Residency Program Director, Faculty Member, or GME Director:

Name of Other Party to Agreement (other health care facility):

Contact Person at Other Facility (needs to respond to email):

Email Address of Contact Person:

Name of Health Care Facility Requesting Resident Affiliation Agreement:

Name of Facility's GME Director or Residency Program Director Submitting Request:

Email Address of Requestor:

Specify Specialty or Content Area of Rotation: *

Send Goals and Objectives Attachments to Graduate Medical Education) *

Yes, I have sent the goals and objectives.

Supervising Physician at Rotation Site: *

Will this affiliation agreement involve any compensation between the parties? *

Yes No

Resident(s) Go to Virginia Mason or Other Health Care Facility for Rotation? *

Is this a one-time single resident rotation?
(If No, skip to Ongoing Rotation section. If Yes, all fields are required.) *

Yes No

Provide Resident Name and PGY Level:

Dates of Rotation Duration (e.g. 9/1/18 - 9/30/18)?

If Part Time During Rotation Period, Specify Hours (e.g. 1/2 day per week):

Is this an ongoing rotation? (If Yes, all fields are required.) *

Yes No

What is the PGY level and rotation duration (e.g. 4 weeks)?

Number of Resident Rotations Per Year (e.g. 10-15 residents do rotation annually)

If Part Time During Rotation Period, Specify Hours (e.g. 1/2 day each week):

Authentication *

* Required

Graduate Medical Education

Graduate Medical Education

Graduate Medical Education

Request for Affiliation Agreement for Resident Rotation

Submitter Information
(If Virginia Mason submitting - all fields are required)

Submitter Information
(If other health care facility submitting - all fields are required)

Resident and Rotation Information
(Must be completed by all requestors)

Single Resident Rotation

Ongoing Rotation

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Graduate Medical Education

Graduate Medical Education

Graduate Medical Education

Request for Affiliation Agreement for Resident Rotation

Submitter Information(If Virginia Mason submitting - all fields are required)

Submitter Information(If other health care facility submitting - all fields are required)

Resident and Rotation Information(Must be completed by all requestors)

Single Resident Rotation

Ongoing Rotation

Submitter Information
(If Virginia Mason submitting - all fields are required)

Submitter Information
(If other health care facility submitting - all fields are required)

Resident and Rotation Information
(Must be completed by all requestors)