<p> EAST JEFFERSON GENERAL HOSPITAL MEDICAL RESIDENT LETTER OF AGREEMENT</p><p>Please fax to (504) 454-5656 or email to [email protected] For questions, please contact David Potter (504) 454-4283</p><p>Name: ______</p><p>Address: __2020 Gravier St. Suite B. New Orleans, LA 70112 </p><p>School Affiliation: ______LSUHSC______</p><p>Specialty Training: _____Ophthalmology______</p><p>House Officer Level ______</p><p>Phone Number: ______</p><p>Beeper/Cell Number: ____(504) _423-______</p><p>Birthdate: ______</p><p>Social Security # ______</p><p> 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.</p><p>Medical Resident Date</p><p>EJGH Chief Medical Officer Date</p><p>10/22/04 Residency Cost Reporting Information FYE: 12/31/2013</p><p>Resident Name (First, MI, Last): ______</p><p>Social Security Number: ______-______-______</p><p>Type of Residency: _____Ophthalmology______</p><p>Is this the resident’s initial choice of residency type? ______</p><p>If not, what was the resident’s initial residency choice? ______</p><p>Was this a new resident during this FYE: ______</p><p>Dates of EJGH Residency during 2013: From__7/2013__ to ____6/2016___</p><p>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? ______</p><p>School Graduated From (Medical or Other):</p><p>Graduation Date (MM/DD/YYYY): ___/___/_____</p><p>Is Resident Foreign? ______</p><p>If yes, Provide Foreign Student Certification Number and please attach copy: ______</p><p>Has resident taken leave of absence or not trained for any period since graduation date? ______</p><p>If so, detail dates of absence and reason why: ______</p><p>Prepared by:______</p><p>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)</p>