Extra-Hospital Rotation Form

Please list below all house officers on your service who were not actively participating in clinical work at NCBH during the current month. This list should include all house officers on extra-hospital rotation and study programs, clinics, doctor's offices, locum tenems, LOA's, research, etc.

See the Guidelines for Graduate Medical Education (GME) Rotations Outside WFBMC PDF with any questions.

Please submit the form to the Medical Staff Office by the end of this month. If you have no one to list, please indicate and submit. If you have more rotating residents than the form allows, please complete multiple forms.

 

Your Name:
Your Email:
Program:
Rotation Month:

  
Name:
Time Away from Institution:
(date)
Location:
(Inclusive of clinics, doctor's offices,
locum tenems, LOA's, Research)

Please specify:
Bill to:
(If applicable)

Name:
Time Away from Institution:
(date)
Location:
(Inclusive of clinics, doctor's offices,
locum tenems, LOA's, Research)

Please specify:
Bill to:
(If applicable)

  
Name:
Time Away from Institution:
(date)
Location:
(Inclusive of clinics, doctor's offices,
locum tenems, LOA's, Research)

Please specify:
Bill to:
(If applicable)

Name:
Time Away from Institution:
(date)
Location:
(Inclusive of clinics, doctor's offices,
locum tenems, LOA's, Research)

Please specify:
Bill to:
(If applicable)

  
Name:
Time Away from Institution:
(date)
Location:
(Inclusive of clinics, doctor's offices,
locum tenems, LOA's, Research)

Please specify:
Bill to:
(If applicable)

Name:
Time Away from Institution:
(date)
Location:
(Inclusive of clinics, doctor's offices,
locum tenems, LOA's, Research)

Please specify:
  Bill to:
(If applicable)

Quick Reference

Residencies

Phone 336-716-3465
Fax 336-716-6415

E-mail
hostaff@wakehealth.edu

Ground Floor, Meads Hall
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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.