Waukesha Family Medicine Residency

Waukesha Family Medicine Residency

Visiting Resident Application Checklist

We’re very glad to hear of your interest in working with us at Waukesha and hope to optimize the experience for you. In order to ensure that full approval of your rotation is achieved through our hospital’s Credentials Committee, we ask that you provide the following materials for review by our Family Practice Residency Review Committee and Medical Staff Credentials Committee. These items include:

1.  A brief letter from you defining your specific goals for doing this rotation in Waukesha (three to five goals would be desirable).

2.  A letter of support from your program director indicating

·  Approval for such an elective

·  That you are a resident in good standing in the upper half of your class

·  Malpractice insurance will be covered by your hospital during the month you are here. Our hospital does not cover visiting residents, and they are considered unlicensed physicians while here.

3.  An updated C.V. (does not need to be extensive).

4.  Agreement form signed by your program director (available on our website)

5.  Preparation for OB experience form. (available on our website)

6.  “Resident Information” form provided by Waukesha Memorial Hospital which will document your credentials and support your eligibility for an elective. (available on our website)

7.  Completion of the Medical College of Wisconsin Affiliated Hospitals, Inc. Non-MCWAH Housestaff Assignment form. (available on our website)

8.  Copies of your State license, DEA certificate, and ECFMC certificate if applicable.

9.  A photograph that can be posted in the hospital.

10.  A Certificate of Insurance or letter stating that you have professional liability insurance that will cover you while you’re here. The professional liability insurance must have, at minimum, primary coverage of 1 million per occurrence/3 million in aggregate, with additional excess insurance coverage available.

11.  Documentation of Healthcare

i.  TB testing within last 11 months

ii.  Measles antibody titer or 2 MMR vaccinations

iii.  Rubella antibody titer or 1 MMR vaccination

iv.  History of chicken pox or positive antibody titer or two documented Varicella vaccinations

v.  Hepatitis B vaccine series or positive HBSAB titer

vi.  Documentation of Flu Vaccination

vii.  Documentation of OSHA Bloodborne Pathogen training within last 11 months.

In order for these materials to be reviewed by the above committees, they are needed three months in advance of the rotation. You may fax your application (except the photo) to Jennifer Kreis at (262) 928-4075 or scan it in and email to . Jennifer will contact you a few weeks before your arrival. If you have any questions or concerns, please don't hesitate to call her at (262) 548-6927.

We look forward to working with you.