Agreement Form Between Waukesha Memorial Hospital And

Resident Applying ______Time at Waukesha______

Dear Residency Director: Since your resident has requested an elective rotation with our program, we ask that you complete the following form to assist us in the processing of the application.

1. Please rate this resident’s knowledge base and clinical skills in comparison with all present and past trainees. (Circle your assessment) First Quartile Second Quartile Third Quartile Fourth Quartile Comments

2. Does this resident require remediation in OB?

3. Has this resident had any disciplinary issues or difficulties encountered on rotations as a result of academic performance, behavioral problems, or health, psychological, or chemical dependency problems? Yes No If yes, please explain:

4. To the best of your knowledge, has this resident been involved in medical malpractice claims, or misdemeanors or felonies (other than traffic violations)? Yes No

5. Rate this resident’s ability to work with others: (rate as: Excellent, Very Good, Fair or Poor) please circle one below:

Patients Peers Supervising Nursing Support Staff Physicians E VG F P E VG F P E VG F P E VG F P E VG F P Comments

6. Rate this resident’s other personal attributes: (rate as: Excellent, Very Good, Fair or Poor) please circle one below: Professionalism Reliability Work Ethic E VG F P E VG F P E VG F P

Comments

Please provide any other relevant comments to this resident’s performance.

On the reverse is a form you must complete in order for the resident to qualify for this rotation. Thank you.

Sincerely, Susanne Krasovich, MD AGREEMENT FORM Between Waukesha Memorial Hospital and ______Family Practice Residency Program

RE: Visiting Resident Qualifying in Medical Resident Count for Waukesha Memorial Hospital

This agreement for the month of ______acknowledges that ______(month/year) (Resident Name) will be rotating at Waukesha Memorial Hospital and will be included in the resident count for Medicare reimbursement. Although Waukesha Memorial Hospital may incur some of the costs for this visiting resident (i.e., housing), the stipend and benefits will continue to be paid by the resident’s primary employer.

______(Signature) Susanne Krasovich, MD Residency Faculty Coordinator for Obstetrics ______Waukesha Family Practice Residency Program (Print or Type Name)

______(Title)

D:\Docs\2017-12-29\02bd0a1192f3c3f1b4c9b33c0586b100.doc