East Jefferson General Hospital

EAST JEFFERSON GENERAL HOSPITAL MEDICAL RESIDENT LETTER OF AGREEMENT

Please fax to (504) 454-5656 or email to [email protected] For questions, please contact David Potter (504) 454-4283

Name: ______

Address: __2020 Gravier St. Suite B. New Orleans, LA 70112

School Affiliation: ______LSUHSC______

Specialty Training: _____Ophthalmology______

House Officer Level ______

Phone Number: ______

Beeper/Cell Number: ____(504) _423-______

Birthdate: ______

Social Security # ______

 Residents must comply with all the requirements and responsibilities established by the medical staff bylaws, rules and regulations and hospital policies (see attachment).  Residents may attend meetings and conferences of the Medical Staff that are open to all Medical Staff members.  All residents must wear and EJGH nametag at all times while in the hospital.  All residents will sign a statement indicating their understanding of and agreement with the Medical Resident Practice Guidelines policy prior to exercising any privileges at EJGH (see attachment). I have read and agree to comply with the rules and regulations stipulated in the Medical Resident Practice Guidelines policy.

Medical Resident Date

EJGH Chief Medical Officer Date

10/22/04 Residency Cost Reporting Information FYE: 12/31/2013

Resident Name (First, MI, Last): ______

Social Security Number: ______-______-______

Type of Residency: _____Ophthalmology______

Is this the resident’s initial choice of residency type? ______

If not, what was the resident’s initial residency choice? ______

Was this a new resident during this FYE: ______

Dates of EJGH Residency during 2013: From__7/2013__ to ____6/2016___

Residency Year: Between 1/1/13 and 6/30/13: ______year Was residency year completed at the end of this period? ______Residency Year: Between 7/1/13 and 12/31/13: _PGY2_year Was residency year completed at the end of this period? ______

School Graduated From (Medical or Other):

Graduation Date (MM/DD/YYYY): ___/___/_____

Is Resident Foreign? ______

If yes, Provide Foreign Student Certification Number and please attach copy: ______

Has resident taken leave of absence or not trained for any period since graduation date? ______

If so, detail dates of absence and reason why: ______

Prepared by:______

Phone:______Please provide a copy of the resident’s rotation schedule for the applicable periods during the FYE. (This will be provided by Education Program Manager)