The University of Toledo

Required Forms/Information for Employment

Forms that need to be Completed, Signed, and Submitted to the GME Office prior to April 15^th.

Instructions for Completion of Forms

New/Incoming Housestaff Documentation Completion Checklist

Post Employment Information  

Invention Reporting and Assignment Obligations Statement 
       Please read the Patent Policy 3364-70-04 (informational only, please read – do not need to submit)

Residency Health Requirement Form

Compact Between Resident Physicians and Their Teachers

Employee Certification of Understanding Ethical Conduct Statement  
       Ethical Conduct Policy Book (informational only, please read – do not need to submit)

Confidentiality Statement
       Confidentiality of Patient Information Policy 3364-15-10(informational only, please read – do not need to submit)

Statement Concerning Your Employment in a Job Not Covered by Social Security

Public Employment Declaration Statement Regarding Material Assistance/NonAssistance to a Terrorist Organization 
       Terrorist Exclusion List (informational only, please read – do not need to submit)

Criminal Records Check Authorization to Release Information
       Criminal Records Check Policy 3364-86-034-00 (informational only, please read – do not need to submit)

Family Education Rights and Privacy Act (FERPA) Authorization Form

Educational Commission for Foreign Medical Graduates (ECFMG) Authorization Form

Document/Records Release Authorization

Non-Resident Alien Information Form

Materials to be completed On-Line Prior to the Beginning of Your Residency/Fellowship Program

Health Insurance Portability and Accountability Act (HIPAA)

National Provider Identifier (NPI)

• NPI Registration
• NPI Registration Instructions

Materials to be completed upon receipt of your UTAD account. This is done on-line, no paper work to be submitted to GME office. Instructions for completion are located under the Required Forms/lnstructions for Employment -Information for Completion of Forms link on the GME website:

• Federal W-4 Tax Form and State Tax Withholding Form (Ohio / Michigan)
• Employee Direct Deposit Authorization Form

 
Materials to Bring to Graduate Medical Education Orientation

I-9 Employment Form and List of Acceptable Documents (as noted on page 5 of this document)

           

            You must bring one (1) acceptable item from List A

                                                OR

            You must bring one (1) acceptable item from List B and List C

 

The above listed materials must be sent to the Office of Graduate Medical education no later than April 15^th.