instructions for completing the ...uthscsa.edu/gme/documents/incoming residents/2009 gme forms...

Revised 02/10/2009

All new physicians, regardless of funding source, must complete the University Health System’s (UHS) administrative processing. In order to expedite processing, UHS has various documents available on the www.uthscsa.edu/gme website. Please refer to the instructions below when completing these documents. If your salary and benefits are provided by University Health System, all forms must be completed. If your salary and benefits are provided directly by another source, i.e. military, etc., do not complete the W-4 and direct deposit form. Upon completion of these documents, return all required forms to University Health System, Professional Staff Services, 4502 Medical Dr., MS#36, San Antonio, TX. 78229. If you have any questions, please call (210) 358-2038 or (210) 358-0163. INSTRUCTIONS FOR COMPLETING THE GENERAL INFORMATION FORM 1. Print or type the form. 2. If you do not have a local (San Antonio) address and telephone number, leave the

sections blank. 3. All Foreign Medical Graduates must list their ECFMG certificate # and expiration date,

as well as VISA status (attach a copy of your VISA, ECFMG certificate, and DS2019). 4. List your House Staff Program and post graduate level of training (indicate the year at

which you will be listed with the program, not the number of years you have trained elsewhere).

5. Sign the bottom of the General Information Form. INTRUCTIONS FOR COMPLETING THE GRADUATE MEDICAL EDUCATION APPLICATION FORM 1. Print or type the form. 2. If you do not have a local (San Antonio) address and telephone number, leave the

sections blank. 3. List of references should include those who have direct professional knowledge of you,

such as professors, previous program director (if any), etc. Include full name and addresses of each professional reference even if references have been requested or provided. A minimum of three (3) references are required. Three forms are included to be provided to each of your references. Clinical references can not be related to you by blood or marriage. Completed forms can be mailed to University Health System, Professional Staff Services, 4502 Medical Dr., MS#36, San Antonio, TX. 78229 or turned in during Orientation in a sealed envelope.

4. Provide full names and complete addresses of medical schools and training institutions. Do not use abbreviations for schools.

5. All check boxes must be marked yes or no. 6. If you answered yes to any of the questions on page four (4) of the General Information

section, you must provide a detailed explanation. 7. Sign the consent for release of information.

Revised 02/10/2009

INSTRUCTIONS FOR COMPLETING THE EMPLOYMENT ELIGIBLITY VERIFICATION FORM (I-9) 1. Complete only the top portion entitled Section 1: Employee Information and Verification.

Do not complete Sections 2 or 3 entitled Employer Review and Verification and Updating and Reverification.

2. If you do not have a local (San Antonio) address, leave the address section blank. 3. All Foreign Medical Graduates who are not U.S. citizens must attach a copy of their

current VISA, foreign passport and DS2019 or Permanent Resident Card to the Employment Eligibility Verification Form. You must check one of the boxes indicating your citizenship status.

4. The documents you must attach are: either one from “List A” or one each from “List B” and “List C”. Photo images and text must be clear and legible.

5. Your documents must be true photocopies of the original documents – DO NOT MAIL ORIGINALS.

6. Sign and date the I-9 form. NOTE: List your name exactly as it appears on your social security card. Do not list nicknames. If you plan to legally change your name, you must obtain a social security card with that name change and forward a copy of the card to Professional Staff Services. INSTRUCTIONS FOR COMPLETING THE W-4 FORM 1. Complete the bottom portion of the form as required. 2. If you do not have a local (San Antonio) address, leave the address section blank. 3. Do not detach the bottom (as indicated on the form). 4. On item #3, indicate withholding status. 5. On Item #5, the number of allowances refers to the number of dependents you are

claiming. 6. On Item #6, an additional amount of taxes (per paycheck) may be deducted, if so desired. 7. Sign and date the form. 8. If you are on a J-1 VISA and plan on claiming exemption from FICA (social security

taxes), you must submit a copy of your current DS2019. 9. Post level annual gross salaries effective July 1, 2009: PL I $42,675.78 PL II $43,868.15 PL III $45,274.59 PL IV $46,858.11 PL V $48,471.85 PL VI $49,858.16 PL VII $51,613.91 PL VIII $53,048.39 There are twenty-six (26) pay periods in a year. Divide your annual salary by 26 to

determine your bi-weekly amount.

Revised 02/10/2009

INSTRUCTIONS FOR COMPLETING YOUR TEXAS OPEN RECORDS ACT FORM 1. Complete the bottom portion of the form as required and indicate whether you wish to

disclose your home address and telephone number to persons other than essential personnel/departments (i.e. human resources, payroll, etc.).

INSTRUCTIONS FOR COMPLETING MISCELLANEOUS FORMS 1. Protective Services Registration/Access/ID Form- Check both new employee and

medical staff, print name, DOB, department, credentials (MD, DO, DDS, etc.), and position/title (indicate House Staff). Under parking permit data, print your primary vehicle registration. Secondary vehicle information is not required. Leave hang tag number/color/type, access card number/type, key control, and locker control information blank. Sign and date the form at the bottom.

2. Authorization Agreement for Automatic Deposit of Salary- Fill in social security number in place of employee ID#, name, and effective date (07/01/2009). Fill in primary bank name, transit number (routing number), and account number. Select checking or savings. If additional financial institutions are desired, fill in the remaining information. Sign the authorization agreement form and attach a voided check for each account.

3. Information Access Request Form- Leave Network User ID, Physician ID, and RC # blank. Indicate House Staff on employee title line, indicate UH as the primary work location, and fill in credentials. Leave remainder of form blank including the authorization section located at the bottom of page.

4. Confidentiality Agreement- Read the Information Asset/Use Policy 2.08.02 on the www.uthscsa.edu/gme website located under Hospital-Specific Policies. After reading the Confidentiality Agreement document, print your name and sign in both specified places (signature and legal signature). A witness must print and sign his/her name.

INSTRUCTIONS FOR COMPLETING THE EMPLOYEE HEALTH CLINIC RESIDENT HEALTH SCREENING QUESTIONAIRE AND IMMUNIZATION AND TB DOCUMENTATION REQUIREMENT FORM 1. Complete both forms in their entirety. 2. If you do not have a local (San Antonio) address, leave the address section blank. 3. You and your physician, NP, or RN must sign and date the Employee Health Clinic

Applicant History form. 4. Attach a copy of your immunization records. INSTRUCTIONS FOR COMPLETING THE NATIONAL PROVIDER IDENTIFIER (NPI) RELEASE/ACKNOWLEDGEMENT FORM 1. DO NOT complete the NPI consent form if you already have an NPI number. 2. Print or type the form in its entirety.

HOUSE STAFF PHYSICIAN GENERAL INFORMATION FORM

(Last) (First) (Middle) Degree Note: Please list name exactly as it appears on your Social Security Card

HOME ADDRESS: HOME TELEPHONE: SPOUSE NAME: (First) (MI) (Last) SOCIAL SECURITY #: CITIZENSHIP: BIRTHDATE: BIRTHPLACE: SEX: ETHNICITY: UTHSC HOUSE STAFF PROGRAM: MEDICAL/DENTAL/PODIATRY SCHOOL (Name and Address):

DATE GRADUATED (MM/DD/YYYYY): FOREIGN MEDICAL GRADUATES: ECFMG CERTIFICATE #: EXP. DATE: VISA STATUS: EXP. DATE: Please Circle Lab Coat Size: 28 36 44 52 30 38 46 54 32 40 48 56 34 42 50 Other Texas Medical/Dental/Podiatry License: LICENSE #: EXP. DATE: DPS #: EXP. DATE: FDEA #: EXP. DATE: NPI#: BASIC CARDIAC LIFE SUPPORT: (Date of Last Certification) ADVANCED CARDIAC LIFE SUPPORT: (Date of Last Certification) IN CASE OF EMERGENCY CONTACT:

(Name) (Relationship) (Phone #)

(Name) (Relationship) (Phone #)

SIGNATURE:

Graduate Medical Education Application Revised 2/09

1

GRADUATE MEDICAL EDUCATION APPLICATION

TRAINING PROGRAM INFORMATION I will begin my training in the Department of: Start Date: Interested in a subspecialty? Yes No If yes, specify subspecialty:

PERSONAL INFORMATION

Last Name: First Name: Middle Initial: Other Last Name:

Street Address City/State Zip Code Phone Number

Date of Birth (MM/DD/YYYY): Place of Birth (City/State):

Marital Status: Name of Spouse:

Do you speak a foreign language? Yes No If yes, what foreign language(s) do you speak? If alien, date of entry (MM/DD/YYYY): What type of Visa do you possess? Visa Number:

Military Status: Branch of Service: Dates of Service: to Type of Discharge:

EDUCATIONAL INFORMATION Do you possess your original medical/dental diploma? Yes No Are you currently certified by an American Specialty Board? Yes No If certified by an American Specialty Board, which specialty Board?


2

UNDERGRADUATE EDUCATION Name of Undergraduate University: Complete Address: Date Degree was Conferred (MM/DD/YYYY):

PROFESSIONAL EDUCATION Name of School: Complete Address: Date Degree was Conferred (MM/DD/YYYY):

INTERNSHIP Name of Institution: Complete Address: Specialty: Dates (MM/DD/YYYY): to

Name of Institution: Complete Address: Specialty: Dates (MM/DD/YYYY): to

RESIDENCY Name of Institution: Complete Address: Specialty: Dates (MM/DD/YYYY): to



3

FELLOWSHIP Name of Institution: Complete Address: Specialty: Dates (MM/DD/YYYY): to


CLINICAL REFERENCES (Must provide at least three (3) peer reference names) Clinical references may be Medical School Professors, Chairman, Program Director or someone of your same discipline.

Last Name First Name Middle Initial Credentials (MD, DO, etc.)






LICENSURE INFORMATION (Please list all past/present state & federal licensures you possess) State in which license was obtained: License # Date Issued State in which license was obtained: License # Date Issued State in which license was obtained: License # Date Issued


4

PROFESSIONAL SOCIETY MEMBERSHIP:

SOCIETY NAME DATES OF MEMBERSHIP

SCHOLARSHIPS, PRIZES AND/OR AWARDS RECEIVED

SCHOLARSHIP/AWARD NAME DATES RECEIVED

TESTING INFORMATION Exam Date of Exam No. of Attempts

USMLE, Part I Grade Average/Percentile: USMLE, Part II Grade Average/Percentile: USMLE, Part III Grade Average/Percentile: NBME, Part I Pass/Fail: NBME, Part II Pass/Fail: NBME, Part III Pass/Fail: FLEX, Component I Score: FLEX, Component II Score: ECFMG, English Test Expiration Date: FMGEMS, Part I Percent: FMGEMS, Part II Percent: ECFMG Number: (Please provide copy)

GENERAL INFORMATION

YES NO 1. Have you ever elected to leave any program of education and/or training prior to completion?

2. Have you ever been asked or directed to leave any program of education and/or training prior to

completion?

3. Are there any actions or proceedings which have involved the imposition of a sanction or dismissal from any program of education and/or training?

4. Are there any actions or proceedings which have involved the suspension and/or revocation of

your license or limited permit in any state or jurisdiction?

5. Have you ever been subject to admonition, reprimand or suspension from any program of education and/or training?

6. Have you ever pleaded guilty or been convicted of a crime or offense other than a minor traffic

violation?

7. Do you currently have any misdemeanor or felony charges pending against you?

8. Do you currently have any health related issues that will prevent you from performing the duties and responsibilities of this program of education and/or training?

If you answered “Yes” to any of the above questions please provide details on a separate page.


5

GAPS IN TRAINING AND/OR MEDICAL EDUCATION If applicable, please provide an explanation of any time gaps in training and/or medical education.

PERSONAL STATEMENT Please describe your professional interests, achievements, and plans for the future. If you wish, you may attach your own personal signed statement.

REMARKS


6

CONSENT FOR RELEASE OF INFORMATION

I authorize the University Health System and its representatives to make inquiries to educational institutions, state licensing boards, American Medical Association, current and/or previous employers, members of the medical staffs and other institutions with which I have been affiliated, regarding education, specific training, experience and current competence. I authorize the University Health System and its representatives to disclose to such persons, employers, institutions or agencies identifying and/or other information necessary to complete the credentialing process. In connection with the evaluation of my application for the Graduate Training Program, I hereby release from liability all representatives of University Health System, its Medical-Dental Staff, and any other individuals, entities and organizations who may provide information to the University Health System and its Medical-Dental Staff, for their acts performed in good faith and without malice. I understand and agree I have the responsibility to produce adequate information for the proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I hereby consent to the release of the above-mentioned information to the officials of the University Health System.

Print Name

Signature Date

Professional Staff Services • 4502 Medical Dr. MS 36-1 • San Antonio, TX • 78229 Fax: (210) 358-4775 Phone: (210) 358-2015

CLINICAL REFERENCE

Applicant’s Name:

Reference Provided By: Print Name and Degree (MD, DO, DDS, etc.)

Address:

Signature:

PRIVILEGES: Please answer all questions based on your personal knowledge and direct observations. Your candor will be greatly appreciated and your answers will be confidential. If your answers require an explanation, please do so in the comment section of this form:

1. Do you personally know the applicant? Yes No

2. What is your affiliation with the applicant?

3. How long have you known the applicant?

4. In what setting(s) and with what frequency have you observed the applicant? (i.e., office, hospital, residency program, etc) Daily Weekly Monthly?

5. Would you recommend the applicant for House Staff appointment to our facility? Yes No

6. Based on personal knowledge and observation, do you believe the applicant has the qualifications and skills necessary to perform the duties and responsibilities of their program of education and/or training? Yes No

PROFESSIONAL BEHAVIOR:

1. To your knowledge, has the applicant ever been convicted of a felony or misdemeanor? Yes No

2. Are you aware of any physical, mental or chemical dependency or condition which would affect the applicant’s competence to practice in his/her field? Yes No

3. To your knowledge, has the applicant ever shown signs of any behavior, drug or alcohol problems? Yes No

EVALUATION: This evaluation should be based on demonstrated performance compared to that reasonably expected of an applicant at his/her similar level of training, experience and background: (Place a check mark in the correct column)

Excellent Good Average Poor Unknown Medical/Clinical Knowledge Clinical Judgment Ability to perform duties/responsibilities requested (physically/mentally) Competence/Technical and Clinical Skills Professionalism Interpersonal Skills Availability Record Keeping Patient Management Practitioner-Patient Relationship Communication skills

Comments:

This document is PRIVILEGED AND CONFIDENTIAL and is the property of the University Health System. This document is only for the use of the intended recipient. Any misuse of this information may result in disciplinary action and/or legal liability.

.

Your prompt return of this recommendation is greatly appreciated

Form W-4 (2009) Purpose. Complete Form W-4 so that youremployer can withhold the correct federal incometax from your pay. Consider completing a newForm W-4 each year and when your personal orfinancial situation changes.

Head of household. Generally, you may claimhead of household filing status on your taxreturn only if you are unmarried and pay morethan 50% of the costs of keeping up a homefor yourself and your dependent(s) or otherqualifying individuals. See Pub. 501,Exemptions, Standard Deduction, and FilingInformation, for information.

Exemption from withholding. If you areexempt, complete only lines 1, 2, 3, 4, and 7and sign the form to validate it. Your exemptionfor 2009 expires February 16, 2010. SeePub. 505, Tax Withholding and Estimated Tax.

Check your withholding. After your Form W-4takes effect, use Pub. 919 to see how theamount you are having withheld compares toyour projected total tax for 2009. See Pub.919, especially if your earnings exceed$130,000 (Single) or $180,000 (Married).

Basic instructions. If you are not exempt,complete the Personal Allowances Worksheetbelow. The worksheets on page 2 further adjustyour withholding allowances based on itemizeddeductions, certain credits, adjustments toincome, or two-earner/multiple job situations.

Two earners or multiple jobs. If you have aworking spouse or more than one job, figurethe total number of allowances you are entitledto claim on all jobs using worksheets from onlyone Form W-4. Your withholding usually willbe most accurate when all allowances areclaimed on the Form W-4 for the highestpaying job and zero allowances are claimed onthe others. See Pub. 919 for details.

Personal Allowances Worksheet (Keep for your records.) Enter “1” for yourself if no one else can claim you as a dependent

A

A ! You are single and have only one job; or

Enter “1” if:

B

! You are married, have only one job, and your spouse does not work; or

B ! Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

! " Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse ormore than one job. (Entering “-0-” may help you avoid having too little tax withheld.)

C C

Enter number of dependents (other than your spouse or yourself) you will claim on your tax return

D

D E

E F

F

Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) "

H

H ! If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions

and Adjustments Worksheet on page 2.

For accuracy,complete allworksheetsthat apply.

! If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $40,000 ($25,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

! If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

! Cut here and give Form W-4 to your employer. Keep the top part for your records.

OMB No. 1545-0074 Employee’s Withholding Allowance Certificate

W-4

Form Department of the TreasuryInternal Revenue Service

" Whether you are entitled to claim a certain number of allowances or exemption from withholding issubject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Type or print your first name and middle initial.

1

Last name

2

Your social security number

Home address (number and street or rural route)

Married

Single

3

Married, but withhold at higher Single rate.

City or town, state, and ZIP code

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

5

5

Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) $ 6

6

Additional amount, if any, you want withheld from each paycheck 7

I claim exemption from withholding for 2009, and I certify that I meet both of the following conditions for exemption.

! Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and ! This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

7

If you meet both conditions, write “Exempt” here "

8

Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete. Employee’s signature(Form is not valid unless you sign it.) "

Date "

9

Employer identification number (EIN)

Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

Office code (optional)

10

Enter “1” if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit

4

If your last name differs from that shown on your social security card,check here. You must call 1-800-772-1213 for a replacement card. "

Cat. No. 10220Q

Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)

Note. You cannot claim exemption fromwithholding if (a) your income exceeds $950and includes more than $300 of unearnedincome (for example, interest and dividends)and (b) another person can claim you as adependent on their tax return.

Nonwage income. If you have a large amountof nonwage income, such as interest or

G

Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

G

! If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible child plus “1” additional if you have six or more eligible children.

! If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

Tax credits. You can take projected taxcredits into account in figuring your allowablenumber of withholding allowances. Credits forchild or dependent care expenses and thechild tax credit may be claimed using thePersonal Allowances Worksheet below. SeePub. 919, How Do I Adjust My TaxWithholding, for information on convertingyour other credits into withholding allowances.

Nonresident alien. If you are a nonresidentalien, see the Instructions for Form 8233before completing this Form W-4.

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Form W-4 (2009)

Complete all worksheets that apply. However, youmay claim fewer (or zero) allowances. For regularwages, withholding must be based on allowancesyou claimed and may not be a flat amount orpercentage of wages.

dividends, consider making estimated taxpayments using Form 1040-ES, Estimated Taxfor Individuals. Otherwise, you may oweadditional tax. If you have pension or annuityincome, see Pub. 919 to find out if you shouldadjust your withholding on Form W-4 or W-4P.

2009

Form W-4 (2009) Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions, claim certain credits, adjustments to income, or an additional standard deduction. Enter an estimate of your 2009 itemized deductions. These include qualifying home mortgage interest,

charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions. (For 2009, you may have to reduce your itemized deductions if your incomeis over $166,800 ($83,400 if married filing separately). See Worksheet 2 in Pub. 919 for details.)

1

$ 1 $11,400 if married filing jointly or qualifying widow(er)

$ $ 8,350 if head of household

2

Enter:

2 $ 5,700 if single or married filing separately

"

!

$ 3

Subtract line 2 from line 1. If zero or less, enter “-0-”

3 $ Enter an estimate of your 2009 adjustments to income and any additional standard deduction. (Pub. 919)

4 $ 5

Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 8 in Pub. 919.)

5 $ 6

Enter an estimate of your 2009 nonwage income (such as dividends or interest)

6 $ 7

Subtract line 6 from line 5. If zero or less, enter “-0-”

7 Divide the amount on line 7 by $3,500 and enter the result here. Drop any fraction

8

8 Enter the number from the Personal Allowances Worksheet, line H, page 1

9

9 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,

also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

10 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)

Note. Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)

1 2

Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $50,000 or less, do not enter more than “3.”

2 3

If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet

3 Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to calculate the additional

withholding amount necessary to avoid a year-end tax bill. Enter the number from line 2 of this worksheet

4

4 Enter the number from line 1 of this worksheet

5

5 Subtract line 5 from line 4

6

6 $ Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here

7

7 $ Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed

8

8 Divide line 8 by the number of pay periods remaining in 2009. For example, divide by 26 if you are paid

every two weeks and you complete this form in December 2008. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

9

$ 9

Privacy Act and Paperwork Reduction Act Notice. We ask for the information onthis form to carry out the Internal Revenue laws of the United States. The InternalRevenue Code requires this information under sections 3402(f)(2)(A) and 6109 andtheir regulations. Failure to provide a properly completed form will result in yourbeing treated as a single person who claims no withholding allowances; providingfraudulent information may also subject you to penalties. Routine uses of thisinformation include giving it to the Department of Justice for civil and criminallitigation, to cities, states, the District of Columbia, and U.S. commonwealths andpossessions for use in administering their tax laws, and using it in the NationalDirectory of New Hires. We may also disclose this information to other countriesunder a tax treaty, to federal and state agencies to enforce federal nontax criminallaws, or to federal law enforcement and intelligence agencies to combat terrorism.

The average time and expenses required to complete and file this form will varydepending on individual circumstances. For estimated averages, see theinstructions for your income tax return.

4

Table 1 All Others

Married Filing Jointly

If wages from LOWESTpaying job are—

Table 2 All Others

Married Filing Jointly

If wages from HIGHESTpaying job are—

Enter online 7 above

If wages from HIGHESTpaying job are—



If wages from LOWESTpaying job are—

You are not required to provide the information requested on a form that issubject to the Paperwork Reduction Act unless the form displays a valid OMBcontrol number. Books or records relating to a form or its instructions must beretained as long as their contents may become material in the administration ofany Internal Revenue law. Generally, tax returns and return information areconfidential, as required by Code section 6103.


0123456789

10

If you have suggestions for making this form simpler, we would be happy to hearfrom you. See the instructions for your income tax return.

$0 -4,501 -9,001 -

18,001 -22,001 -26,001 -32,001 -38,001 -46,001 -55,001 -60,001 -65,001 -75,001 -95,001 -

105,001 -

$4,5009,000

18,00022,00026,00032,00038,00046,00055,00060,00065,00075,00095,000

105,000120,000 120,001 and over

0123456789

101112131415

$0 -6,001 -

12,001 -19,001 -26,001 -35,001 -50,001 -65,001 -80,001 -90,001 -

$6,00012,00019,00026,00035,00050,00065,00080,00090,000

120,000 120,001 and over

$0 -65,001 -

120,001 -185,001 -

$550910

1,0201,2001,280

330,001 and over

$65,000120,000185,000330,000

$0 -35,001 -90,001 -

165,001 -

$550910

1,0201,2001,280

370,001 and over

$35,00090,000

165,000370,000

Texas Public Information Act As an employee of the University Health System, certain information in the custody of University Health System regarding you and your employment must be disclosed by University Health System to any person requesting such information under the Texas Public Information Act. Your name, sex, ethnicity, salary and date of employment are examples of information that must be disclosed by University Health System to any person making such a request. Information relating to your home address (including e-mail addresses) home telephone number (including cell, pager or other numbers through which you may be reached) social security number and/or information that reveals whether you have family members must also be disclosed by University Health System unless you choose to have University Health System treat this information as confidential and exempt from disclosure. If you submit a signed written statement to the Administrative Director of Human Resources (the main personnel officer), stating that you do not wish information to be disclosed, relating to your home address (including e-mail addresses), home telephone number (including cell, pager or other numbers through which you may be reached), social security number and/or information that reveals whether you have family members, University Health System by law can honor your request. Below is a form, which should be filled out, dated and signed by you and returned to the Director of Human Resources indicating your choice in this matter. I understand that under the Texas Public Information Act, if I fail to state my choice, the information is subject to public access. TO: Human Resources Director ____ Please close public access and do not disclose information relating to my home address (including e-mail addresses), home telephone number (including cell, pager or other numbers through which I may be reached), social security number and/or information that reveals whether I have family members, to any person under the Texas Public Information Act. ____ You may disclose information relating to my home address (including e-mail addresses), home telephone number (including cell, pager or other numbers through which I may be reached), social security number and/or information that reveals whether I have family members, to any person under the Texas Public Information Act. Employee Name: (Please type or print) Employee Signature: Date:

Revised: March 1, 2007

Protective Services Registration/Access/ID Form

NEW EMPLOYEE DATA CHANGE MEDICAL STAFF VOLUNTEER

NAME (LAST, FIRST, MI) R/C

PHOTO ID/STATE DATE OF BIRTH EMPLOYEE #

UHS

DEPARTMENT CREDENTIALS

POSITION/TITLE COMPLETED BY

PARKING PERMIT DATA (Primary Vehicle)

VEHICLE YEAR MAKE MODEL COLOR BODY STYLE

LICENSE PLATE NUMBER STATE OF ISSUE ACCESS CARE #/TYPE

FACILITY

HANG TAG ISSUED (#/COLOR/TYPE)

PARKING PERMIT DATA (Secondary Vehicle)

VEHICLE YEAR MAKE MODEL COLOR BODY STYLE

LICENSE PLATE NUMBER STATE OF ISSUE

FACILITY ACCESS LEVELS ASSIGNED

KEY CONTROL

SERIES KEY NUMBER ISSUE NO. DATE IS/RT







LOCKER CONTROL

LOCKER NO. ROOM NO. UHS PADLOCK (Y/N) PADLOCK NO.

I have been informed of my proper parking area and I have received information regarding the Health System's parking policies, rules, and regulations. I understand that, though my vehicle is properly registered, I am not guaranteed a parking space and any violations of UHS parking policies, rules, and regulations may result in revocation of parking authorization and/or towing of my vehicle at my risk and expense. I further understand that all items issued to me by Protective Services through Employee Registration & Identification are security-controlled items. It is my responsibility to safeguard these items. Any loss of these items must be reported immediately. The University Health System assumes no liability or responsibility for any personal property on Health System premises. Replacement fees are established by Protective Services in accordance with established polices & procedures. SIGNATURE DATE

INFORMATION ACCESS REQUEST FORM

PLEASE SUBMIT THIS COVERSHEET WITH ALL ACCESS REQUESTS-BOTH NEW IDS AND UPDATES

Please complete all of the information below. Incomplete forms will be rejected.

TODAY’S DATE: ______________ START DATE: ______________ USER’S NAME: _____________________________________________________________________________ LAST NAME FIRST NAME MIDDLE INITIAL LAST 4 DIGIT’S OF THE USER’S SSN: _________________________ DEPARTMENT NAME: _______________________________________ NETWORK USER ID: __________________________________________ EMPLOYEE’S TITLE: _________________________________________ PRIMARY WORK LOCATION: ___________________________________________________ (UH, UHCD, UFHCN, UFHCNW, UFHCSW, UFHCSE, UHBC, UCCH, DHCS, UTHSC, CTRC, UPG, ETC.) RC NUMBER: ______________ PHONE EXT./PAGER NBR: ________________________ CREDENTIAL: __________ (MD, PA, MS3, MS4, RN, CRRT, LVN, etc.) PROVIDER ID#:______________DEA#:__________________DPS#:____________________State Lic #:___________________ HOUSESTAFF DEA#: AM1472579 ___ ___ ___ ___ ___ DPS#: 10046768 ___ ___ ___ ___ ___ State Lic #:_______________

FACULTY HOUSESTAFF/RESIDENT Military Rotator (__________to___________)

ALLIED HEALTH W/ PRESCRIPTIVE AUTHORITY

Visiting Medical Student (____________to____________) Authorization letter from UT Registrar’s office must be attached. Requests without authorization will be rejected.

Contract/temporary (______________to___________)

Researcher or Research Monitor (_______________to_________________) for IRB#______________________ AUTHORIZATION: (DIRECTOR/SUPERVISOR) PRINT:_____________________________________________________________________________________ NAME TITLE SIGNATURE:_______________________________________________________________________________ E-MAIL ADDRESS FOR NOTIFICATION: _____________________________________________________ (not required if your email is @uhs-sa.com) Have any questions? Call Data Security at 358-0640. You may route completed access forms to us at MS124-1, fax them to us at 358-0340, or bring them by the Computer Room on the 1st floor of the Hospital 24-hours a day. Rev. 09/08

UNIVERSITY HEALTH SYSTEM CONFIDENTIALITY AGREEMENT

I, the undersigned, hereby acknowledge receipt of a 4. Issuance of New Userid and Password. If I userid and password giving me access to the Hospital have any reason to believe that the confidentiality of Information System of the University Health System, my userid and password has been compromised, I Bexar County, Texas (hereafter referred to as the will notify the Data Security Administrator University Health System) computer system. I immediately so that the suspect userid and password understand and acknowledge that this userid and may be deleted and a new userid and password password combination is unique to me and is the assigned to me. electronic equivalent of my signature, with no difference in liability existing between my written 5. Responsibility for Self. I recognize that I am and electronic signatures. responsible for all actions performed at a workstation

activated with my userid and password; therefore, I I further understand that this userid and password will terminate the session before leaving the May give me access to confidential patient health care workstation. and financial information, employee personnel information, physician information, and business 6. Responsibility for Others. If applicable, I information relating to the University Health System hereby specifically accept responsibility for ensuring (herein referred to as Information), and that the that my office staff, agents, employees, or any other University Health System regards maintaining the person acting on my behalf, in connection with confidentiality of this information to be of paramount Information, will abide by the terms and conditions importance. of this Confidentiality Agreement.

Therefore, in consideration of the foregoing, I agree 7. Violation of Conditions. I recognize that to the following: violation of any of these conditions may result in

withdrawal of computer access, termination of 1. Information to be confidential. All Information employment for employees, denial of hospital access obtained by me, or on my behalf, whether by me, my for non-employees, and other disciplinary actions. office staff, agents, employees or any other person whatsoever, will be maintained in confidence by me, 8. Indemnification. I agree to indemnify and hold or by any other person acting on my behalf. I further the University Health System harmless from any and agree that Information will be obtained and used only all liability, loss, or damage, including attorney’s as necessary to perform my professional fees, that the University Health System may suffer as responsibilities. a result of claims, demands, costs, or judgements

against it arising from the breach or violation of any 2. Scope of Information. I agree that I will use the provisions of this Agreement by me and/or my staff, userid and password only to obtain access to that agents, employees, or any other person acting on my Information necessary for me to perform my behalf. I further agree to notify the University Health Professional responsibilities. System in writing, within ten (10) days by registered

U.S. Mail, of any claim made against me or my 3. Use of Userid, Password and Signature Stamp. office staff, employees, and/or agents, on the I will not disclose my userid and password to any person or obligations indemnified against herein. entity, nor will I attempt to learn or use any other person’s userid and password. I will not share my Signature Stamp with any person. I have also received, read, and understood the Information Asset/Use Policy 2.08.02 IN WITNESS WHEREOF, I have executed this agreement at San Antonio, Texas, this _________ day of __________, 20_____.

HOSPITAL INFORMATION SYSTEM USER WITNESS

PRINT: ___________________________________ PRINT: ___________________________________

SIGNATURE: ______________________________ SIGNATURE: ______________________________ USER’S LEGAL SIGNATURE (AS IT APPEARS ON LICENSE): ______________________________________

Employee Health Clinic

Resident Health Screening Questionnaire

The following questions and responses will be used to evaluate your current health status. We hope that this screening will help identify areas that may be of concern to you, and allow us to assist in discovering methods to address these health concerns. This questionnaire is voluntary. We appreciate your time and we look forward to serving you. Please note that this screening does not replace your yearly screening at your Primary Care Provider’s office.

General Information:

Name: ___________________________________________________ SSN: ______________________________

Address: __________________________________________________________ Phone: _____________________

Position: ______________________________________ Department: _____________________________________

List any allergies to medications or foods.________________________________________________________________

For everyone: Do you smoke? Yes No

If yes: • How often/how much do you smoke? __________ / _____________ • Are you interested in quitting? Yes No

Do you use smokeless tobacco? Yes No If yes, are you interested in quitting? Yes No

Health Screening:

Please list any illnesses, hospitalizations, or surgeries you have had within the last year: __________________________________________________________________________________________________ Please list all of the medications you are currently taking: ____________________________________________________________________________________________________________________________________________________________________________________________________

Have you experienced any of the following within the past month? Fever? Yes No Cough? Yes No Fatigue? Yes No Trouble swallowing? Yes No Dizziness? Yes No Syncope (passing out)/chest pain? Yes No Swelling in the legs? Yes No Joint pain? Yes No Suspicious skin lesions? Yes No Excessive thirst or hunger? Yes No Headache/blurred vision or problems with your vision? Yes No Unintentional weight loss or gain of at least 10 pounds? Yes No Change in bladder habits, frequent urination? Yes No Difficulty or burning with urination? Yes No Abdominal pain, heart burn, nausea/vomiting/diarrhea/constipation or change in bowel habits? Yes No

Please indicate if you or anyone in your family has had a history of: Glaucoma Yourself Family Member Heart disease Yourself Family Member High Blood Pressure Yourself Family Member Diabetes Yourself Family Member Asthma Yourself Family Member Allergies Yourself Family Member Cancer Yourself Family Member Kidney disease Yourself Family Member Seizures Yourself Family Member Thyroid disease Yourself Family Member Eating Disorders Yourself Family Member Arthritis Yourself Family Member Depression/psychological problems Yourself Family Member

Nurse Signature: ________________________________________ Date: ____________________________

Revised 02/20/2007

Immunization/Immunity/and TB Documentation Requirements Name: Pager:

Complete this form and attach it to the copies of your immunization record and submit to Professional Staff Services. 1. When was your last Td? If longer than 10 years, then you will need this vaccination. Date

2. Did you have varicella as a child? If not, then you will need proof of vaccination or proof of a positive antibody titer. Date

3. Provide proof of receiving 2 MMr’s or proof of immunity to rubella and measles.

4. Provide proof of receiving 3 hepatitis B vaccinations and a positive antibody titer. If you do not have proof of receiving 3 vaccinations, then documented proof of a positive antibody titer is acceptable.

5. Provide documentation of a tb skin test in the last 3 months.

6. If you have had a positive tb skin test in the past you will need to provide documentation of a chest x-ray.

Date of your first positive tb skin test: Date

How long did you take INH? Date

If you are deficient in either vaccination requirements or immunity and elect not to be vaccinated, you will need to follow-up in the Employee Health Clinic at University Hospital to document that you are declining the vaccine. This may also delay your clearance. Any pending matters with the above recommendations may be addressed to the Employee Health Clinic

Questions/Comments or Concerns?

NATIONAL PROVIDER IDENTIFIER (NPI) RELEASE/ACKNOWLEDGEMENT FORM

I hereby authorize the following individuals including, without limitation, University Health System, its representatives, employees and/or designated agent(s) to obtain an NPI number on my behalf. This is to include authorization to release NPI information to health plans, clearinghouses, insurance providers and any entity that may require the information for use in electronic standard transactions for billing purposes as outlined in the Federal Register (The Health Insurance Portability and Accountability Act of 1996 (HIPAA). 45 CFR § 162.410-162.414 and 162.610 I acknowledge I have read and understand the foregoing release. I understand and agree a facsimile or photocopy of this release shall be as effective as the original. Please print or type all information. Do not complete if you already have an NPI number. ____________________________________ Department/Specialty ____________________________________ What is your mother’s maiden name? (Security question on NPI application) ____________________________________ Name exactly as it appears on social security card ____________________________________ Signature ____________________________________ Date

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