Program Letter of Agreement
DATE
Home/Sponsoring Residency Program Participating/Off-SiteRotation
RESIDENCY PROGRAMINSTITUTION NAME
PD NAMEPD/CEO/DIRECTOR NAME
Residency Program DirectorResidency Program Director
ADDRESSADDRESS
CITY, STATE ZIPCITY, STATE ZIP
Office: (999) 999-9999Office: (999) 999-9999
This document serves as an agreement between the SPONSORING/HOME INSTITUTION’S RESIDENCY/FELLOWSHIP PROGRAM and the PARTICIPATING/OFF-SITE ROTATION as an ongoing commitment to resident/fellowship education. This Letter of Agreement is effective from MM/DD/YYYY and will remain active for five years, or until updated, changed or terminated by both parties.
GRADUATE MEDICAL EDUCATION GENERAL POLICIES:
- To receive credit for the rotation, residents must be on duty a minimum of daysduring the 1 month rotation.
- No vacation or leave is allowed during a two-week off-site rotation.
Contact Person or Coordinator:
Name: Phone #: ()
Email Address: Fax #: ( )
Duration or Rotation dates:
Persons Responsible for Education and Supervision
- At Sponsoring Institution: Program Director
- At Participating Site: Local Director
- List Faculty Supervisor(s):
The above mentioned people are responsible for the education and supervisionof the residents/fellows while rotating at Participating Site.
RESPONSIBILITIES
In cooperation with Program Director, Site Director and the faculty at Participating Site are responsible for the day-to-day activities of theResidents/Fellows to ensure that the outlined goals and objectives are metduring the course of the educational experiences at Participating Site.
The faculty at the participating/off-site rotation must provide appropriate supervision of residents/fellows in patient care activities and maintain a learning environment conducive to education in the ACGME competency areas.
The faculty must evaluate the performance of residents/fellows in a timely manner during each rotation or similar educational assignment. In addition, faculty supervisor(s) is/are also responsible for documenting the evaluation upon completion of the assignment.
Resident and Rotation Evaluation Forms are attached for completion and submission at the end of the off-site rotation. (Home Residency Program Coordinator must provide a copy of the Evaluation Form to the Participating/Off-site coordinator.)
Content of Educational Experiences:
The content of the educational experience has been developed according to ACGME Residency/Fellowship Program Requirements and are delineated in the attached document.
Policies and Procedures that Govern Residents/Fellows Education
Residents/Fellows will be under the general direction and policies of TTUHSC, the Graduate Medical Education Policies & Procedures, the Home Program’s Residency/Fellowship Manual, and under the Participating/Off-Site rotation’s policies & procedures.
Signature Page
Home/Sponsoring Residency Program:
Residency Program Director Signature Date
Department of ------
Participating/Off-SiteRotation:
PD,CEO or Designated Rep.
Title Signature Date
Graduate Medical Education
Assoc. Dean, DIO Signature Date
Office of Graduate Medical Education
Revised: September 5, 2013Page 1