Application - Visiting Resident Manager

Rotation Information

I hereby apply to the Vanderbilt University Medical Center for residency/clinical fellow training rotation:

Department/Division of

Currently training at UT, Meharry, or ETSU?

Preferred Start Date

Preferred End Date

Personal Information

First Name

Middle Name

Last Name

Name Suffix

Degree Suffix

Date of Birth

NPI Number

SSN (digits only)

COVID-19 vaccination status

I have already had a complete series of COVID-19 vaccine (both doses of a 2-dose series or have received a 1-dose series such as Johnson & Johnson) OR I have had the 1st dose and will get dose 2 prior to the start of my rotation.

I will not be fully vaccinated for COVID-19 prior to starting my rotation.

Address

City

State

Zip Code

Email (Use personal email address only)

Phone Number

Educational Background

Graduates of Foreign Medical Schools must provide a valid ECFMG certificate.

Medical School (Include Dates)

Current Residency

Current Residency
(hospital, location, specialty, and dates)

Program ACGME Accredited?

Program Coordinator Name

Program Coordinator Phone

Program Coordinator Email

Program Director Name

Program Director Email

Professional Experience

Previous residency

Have you previously completed a visiting rotation at VUMC?

If yes, provide your previous VUMC ID

Licensure

Are you currently licensed to practice medicine?

If so, indicate the state and license

License Number

Malpractice Insurance

Have you had any cancellations, non-renewals or limits placed on your malpractice coverage?

If yes, provide a summary of details

Have you been party to any malpractice liability claims, suits and/or settlements?

If yes, provide a summary of details

Do you have current malpractice coverage?

Carrier

Coverage Limits
(Min of $1 million/$3 million

Criminal Record

Have you ever been convicted of a crime, other than a minor traffic violation?

If yes, provide a summary of details

Are there any charges currently pending against you?

If yes, provide a summary of details

Health Insurance Coverage

Provided by

Plan/Policy Number

Application for Temporary Rotation as a Resident/Clinical Fellow at Vanderbilt University Medical Center

Rotation Information

Personal Information

Address

Educational Background

Current Residency

Professional Experience

Licensure

Malpractice Insurance

Criminal Record

Health Insurance Coverage