Required Forms/Information for Employment

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

New/Incoming Housestaff Documentation Completion Checklist

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 and Respiratory Evaluation Medical Questionnaire

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)

Expected Behaviors Form

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

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

Educational Commission for Foreign Medical Graduates (ECFMG) Authorization Form

Document/Records Release Authorization

Non-Resident Alien Information Form

Fraud Acknowledgement Form Please read the ORC 117.103 & 123.341 codes and fraud hotline (informational only, please read - do not need to submit)

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

Health Insurance Portability and Accountability Act (HIPAA)

Institute for Healthcare Improvement (Fundamentals Patient Safety PS101 and Fundamental of Improvement QI101

IHI Instructions

National Provider Identifier (NPI)

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

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.