UNIVERSITY OF PITTSBURGH PHYSICIANS / UNIVERSITY OF PITTSBURGH SoM
Offer Letter Cover Form
REQUESTOR INFORMATION:
Requestor/Contact Name:______Phone Number: ______
Email Address:______Fax Number: ______
Department/Division: ______
CANDIDATE INFORMATION:
Candidate’s Name:______Medical Specialty: ______
Candidate’s Email ______
Current Position (rank): ______Current Employer(s): ______
Proposed UPP/SoM Position (rank):______Proposed Length of Appointment: ______
Proposed Start Date: ______ Non-Tenure Tenure Stream Tenure
Reason for Hire:
New
ReplacementFor whom?______Termination Date:______
Other (explain)______
Position Number: ______Is Position Budgeted? Yes No
UPMCCostCenter ______
Proposed Employment Status: Full-Time Part-Time Casual Flex Full Time (only if PT SoM)
Proposed (Actual) Total Work Hours: ______
Proposed Clinical Effort % (should match proposed Exhibit): ______
US Citizen: YES NO If not US Citizen, list Visa Status ______
NOTE: If this physician’s employment eligibility is via a J1, F1 or F2 visa status, this physician is not employment
eligible within UPP. Employment for this physician MUST be through the GME program.
Will this candidate have privileges at a UPMC facility? Yes No
If yes, which facility(ies) will you be requesting privileges for? (pleasecheck the selected locations)
ChildrensHospital of Pittsburgh of UPMCUPMC Bedford
ChildrensHospital of Pittsburgh of UPMC, NorthUPMC St. Margaret
ChildrensHospital of Pittsburgh of UPMC, SouthUPMC St. Margaret Harmar Outpatient Center
MageeWomensHospital of UPMCUPMC Horizon
UPMC MercyUPMC McKeesport
UPMC Mercy, SouthSideSurgeryCenterUPMC Northwest
MonroevilleOutpatientCenterUPMC Passavant and Passavant Cranberry
UPMC PresbyterianUPMC Shadyside
UPMCPresbyterianSouthSurgeryCenter
Will this candidate be employed within multiple UPMC entities concurrently (e.g. GME and UPP)? Yes No
UNIVERSITY OF PITTSBURGH PHYSICIANS / UNIVERSITY OF PITTSBURGH SoM
Offer Letter Cover Form - Page 2
CANDIDATE’S NAME:______
PAY CATEGORY UPP Only A C* Z** T (T-32)
* Please list all active grant support which will be transferred to the University of Pittsburgh. Include base salary support
for the proposed faculty member.
*Please list all pending grant support and outline timeline for anticipated grant support (include percentage of base salary
to be funded) for all years of the initial appointment (Year 1, Year 2, Year 3, etc).
**If one or more of these questions can be answered yes, the physician being hired should be classified as Category Z
**Is there a formal match with a specialty-society accredited program? / Yes / No**Are Board certifications offered without a corresponding ACGME program? / Yes / No
**Are there formal educational requirements or competency training that must be reported at the completion
of the program? / Yes / No
**Is there a formal evaluation process of the physician? / Yes / No
**Is the Program Director attesting in any form (letter, certificate, etc) toadditional training for any employed physician? / Yes / No
***Pre-Offer Malpractice Screening Requirement***
Check box to the right certifying that the Pre-Offer Malpractice History Review was completed for this candidate
PLEASE ATTACH COPY OF NPDB APPROVAL E-MAIL
Was a claims history reported/identified during the Pre-Offer Malpractice History Review process? Yes No
*If yes, you must submit a copy of the completed screening form with the offer letter packet. N/A
Check box if a review wasn’t required due to candidate already covered by Tri-Century Insurance
REFERENCE CHECKS:
Name:______Institution:______Date:______Completed By:______
Name:______Institution:______Date:______Completed By:______
Name:______Institution:______Date:______Completed By:______
PROPOSED COMPENSATION: Dep’t. Admin. Approval:______
SoM Base: ______Reviewed by UPP Administration & Physician Relations:
UPP Base: ______Contract Administrator:______
VAMC Base: ______Director, Physician Compensation & Administrative Services
Total Base: ____________
SoM Incentive ______Senior VP, Administrative Services& Physician Relations
SoM Administrative Supplement: ____________
UPP Incentive: ______
UPP Supplement: ______Sent to Dean’s Office for Approval: N/A
UPP Administrative Supplement: ______Date Submitted: ______
Total Proposed Compensation: ______Date Returned: ______
PLEASE DELIVER ALL NON-UPP OFFER LETTERS TO:UNIVERSITY OF PITTSBURGH
DIANE HUCHBER
441 SCAIFE HALL
PHONE: 648-3218 FAX: 648-3222 / PLEASE DELIVER ALL UPP OFFER LETTERS TO:
UPP OFFICE OF THE SENIOR VICE PRESIDENT,
ADMINISTRATIVE SERVICES PHYSICIAN RELATIONS
BETH ZNIDARSIC – EXECUTIVE ASSISTANT
9035 FORBESTOWER
PHONE: 647-8166 FAX: 647-2039