HOUSE STAFF EXIT INFORMATION- FORM A
(Complete form A if you are leaving Vanderbilt)
Instructions:
Provide any and all information for future training and/or the type of medical practice you are pursuing. If the complete business address is not available, provide the city and state. This information will be provided to the Vanderbilt Alumni Office unless you indicate otherwise. Signatures are required from hospital departments to assure all transactions are complete.
Personal Information:S.S.#: Name:
Specialty:
Forwarding home address (if applicable):
Forwarding email address:______
Phone: (_____) _____- ______
Future Plans: (Complete either Section 1, 2, or 3 below)
1. Additional Training: ____ Yes ____ No
If yes, please mark: ____ Residency ____ Fellowship
Specialty: Location:
2. Business/Practice:
____ Solo ____ Medical Staff: ____ Academic ____ Nonacademic
____ Group ____ U.S. Government (Branch: )
____ Partnership
Forwarding Business Name and Address:
Phone: (_____) _____- ______
3. Currently searching for employment: ____ Yes ____ No
If not, please explain:
Cont. on the back…
HOUSE STAFF EXIT INFORMATION- FORM A
Continued
Signatures Required:
Scrub Returns/Scrub Machine Checkout- Kris Stewart (1806 TVC) Date
(Office located by Patient Reg./Guest Services-1st FL Main TVC Lobby)
Medical Center Library (Circulation Desk) Date
Vanderbilt Medical Records Department (Hub) Date
VA Medical Center Medical Records Department Date
Chief of Service or Department Coordinator Date
Vanderbilt Pager and Secure ID Token (Department Coordinator) Date
Mailbox in Vanderbilt Clinic (If applicable, come to GME Office.) Date
Graduate Medical Education Office – Jane Shoun (2807 TVC) Date
(MUST BE THE FINAL SIGNATURE)
PROPERLY DISCARD UNUSED RX PADS (Shred-it bin is located in the GME Office).
RETURN YOUR SOUTH PARKING GARAGE ACCESS CARD TO THE GARAGE ATTENDANT OR AT THE MAIN HOSPITAL GARAGE CENTRAL PARKING OFFICE.
I’m out of here!!!
HOUSE STAFF EXIT INFORMATION- FORM B
(Complete form B if you are staying as Vanderbilt Faculty)
Instructions:
Provide your Vanderbilt business address. This information will be provided to the Vanderbilt Alumni Office. Signatures are required from hospital departments to assure all transactions are complete.
Personal Information:S.S.#: Name:
Specialty:
Forwarding home address (if applicable):
Forwarding email address:______
Phone: (_____) _____- ______
Vanderbilt Business Address:
Phone: (_____) _____- ______
Signatures Required:
Chief of Service or Department Coordinator Date
Vanderbilt Pager and Secure ID Token (Department Coordinator) Date
Mailbox in Vanderbilt Clinic (If applicable, come to GME Office.) Date
Graduate Medical Education Office- Jane Shoun (2807 TVC) Date
(MUST BE FINAL SIGNATURE)
TO ASSURE THAT YOUR PARKING ACCESS CARD DOES NOT DEACTIVATE, CONTACT THE VUMC CENTRAL PARKING OFFICE TO ARRANGE FACULTY PARKING
Go Dores!!!!