Common Contracts
1 similar Training Affiliation Agreement contracts
TRAINING AFFILIATION AGREEMENT REQUEST FORM (SOM)Training Affiliation Agreement • July 19th, 2018
AGREEMENT SUMMARY REQUEST DATE: DATE OF NEXT SCHEDULED ROTATION: TYPE:DOMESTIC INTERNATIONAL TRAINEE TYPE:CLINICAL PSYCH GME OTHER: NO. OF TRAINEES: INCOMING OUTGOING NEW RENEWAL AMENDMENT FREQUENCY OF USE: REGULAR ONE-TIMEFACILITY:HOSPITAL MEDICAL GROUP SINGLE PHYS AGREEMENT REQUIRED BY ACCREDITING ORG? YES NO IF YES, SPECIFY ORG: ACGMEOTHER: UCSF INFORMATION UCSF GME PROGRAMS ROTATING TO AFFILIATE SITES (SPECIFY, IF ANY): UCSF GME REQUESTOR CONTACT:NAME:ADDRESS:CAMPUS BOX:PHONE: FAX:EMAIL: TRAINEE DUTIES: CLINICAL RESEARCH (THE TRAINEE WILL HAVE NO PATIENT CONTACT OR PATIENT CARE DURING THE RESEARCH) PROVIDE BRIEF DESCRIPTION: AFFILIATE INFORMATION SITE NAME:MAILING ADDRESS CONTACT FOR CONTRACT DETAILSNAME: STREET: TITLE: CITY/STATE: EMAIL: ZIP: COUNTRY: PHONE: FAX: PHONE: FAX: MAILING ADDRESS: (IF SAME AS SITE MAILING ADDRESS, CHECK BOX) TRAINING LOCATION DETAILS(IF DIFFERENT THAN ABOVE SITE ADDRESS) SIGNATORY CONTACT DETAILS(IF DIFFERENT THAN ABOVE CONTRACT CONTACT) STREET: NA
