Radiology New Hires

• For Fellows entering ACGME accredited programs please refer to the GME website for new hires.

• For Fellows entering non-ACGME accredited programs please see below.

Radiology Departmental Fellow Document Checklist

The forms listed below are required for employment. These forms are either in Adobe Acrobat PDF format or Microsoft Word . You can download Adobe Acrobat Reader free from here.

Please complete each item and return all forms to:

Darlene Cushman
Administrator
Department of Radiology
University of Rochester Medical Center
601 Elmwood Avenue, Box 648
Rochester NY 14642

Forms that require your signature to be witnessed need to be signed in person at orientation.

• INFORMATION RELEASE. We will need to verify your medical school graduation and any previous training. This document requires your signature.

• WORK HISTORY CHRONOLOGICAL TIMELINE Explanation.
  Click here to view/complete form

• PHARMACY MEMO. Please legibly print your name and program name, and sign your name. This document will be placed on file in the pharmacy.

• RESTRAINT COMPETENCY. Please read the policy and complete the competency by signing on page 2.

• INTELLECTUAL PROPERTY AGREEMENT. Please legibly print your name and program name, and sign your name. This document will be on file in the Office of Research and Project Administration.

• CONFLICT OF COMMITMENT AND INTEREST. Please review this policy and then fill out and sign the Conflict Disclosure Form.

• FEDERAL TAX WITHHOLDING FORM

• NEW YORK STATE TAX WITHHOLDING FORM

• PAIN ASSESSMENT AND MANAGEMENT. Please complete the self-learning module, and return the attestation form. The attestation will be on file in the Radiology Chairman's Office.

• STRONG MEMORIAL HOSPITAL ANNUAL INSERVICE. Please complete the competency questionnaire for SMH employees as well as the Highland addendum.

• MANDATORY HEALTH REQUIREMENTS (See checklist)
  These tests are done by appointment only and can be arranged by calling
  585-275-4955. Please identify yourself as an incoming fellow.

  • Preplacement Health Assessment: The immunization record should be completed and signed by a physician or other official at your health service. A licensed physician or nurse practitioner should complete pages 2-3 of the physical health assessment form; you should complete page 1 of this form.
  • Arrangements for a physical exam and respirator mask fitting can be made through the same office. We recommend that you schedule this appointment while you are in Rochester to secure housing. Your PPD needs to be read 48-72 hours after placement. The forms are available at:
               TB Respirator Information
               TB Respirator Questionnaire

  Your appointment to Strong Memorial Hospital is contingent upon successful completion of a drug and alcohol screening, and must be scheduled at least 7 working days before you plan to begin work.

• ADDITIONAL FORMS TO BE COMPLETED BEFORE BEGINNING WORK:

• UNIFORM HEALTH ASSESSMENT FORM

• UNIFORM EMPLOYMENT APPLICATION FORM

• UR/STRONG HEALTH REQUEST FOR INTERIM PRIVILEGES

• EMERGENCY REQUEST FOR TIME-LIMITED HOSPITAL PRIVILEGES

• STRONG HEALTH IPRO STATEMENT

• SMH STATEMENT OF ASSURANCES

• HIGHLAND HOSPITAL IPRO STATEMENT

• HIGHLAND HOSPITAL STATEMENT OF ASSURANCES

• CLINICAL INFORMATION TRAINING, Part I and Part II

  The University of Rochester Medical Center uses the Clinical Information System (CIS) for lab and microbiology results, radiology reports, dictated reports, provider order entry, etc.

You must take Part I, the computer-based training (cbt) module prior to orientation. The link to the training module is: http://cis.urmc.rochester.edu then choose "education" and "SMH Results CBT." This module will take approximately 45-60 minutes and includes the mandatory hospital confidentiality training.

After taking Part I, the CIS educators will send you an email. If you do not need to take Part II (CIS Provider Order Entry), you will receive an email that explains where you need to go to pick up your CIS account information. If you do need to take Part II (CIS Provider Order Entry), the email will include the date, time, and location for your additional training.

If you do not take the training module, you will not have a training time slot. If you have any questions, please send an email to: CIS_feedback@urmc.rochester.edu.

• ECFMG SPONSORSHIP

Please contact Darlene Cushman at darlene_cushmanr@urmc.rochester.edu or by phone at 585-275-2734 with any questions about your sponsorship. Go to www.ecfmg.org to complete as much of the J-1 application as possible, before sending it to Darlene.

• MANDATORY ORIENTATION
  Attendance at an all-day orientation session is mandatory and must be completed before you can begin work. Radiology orientation has been scheduled for July 2nd at 8:30AM in the Radiology Library (Room 3-4330).

  During the orientation you will be signing up for University benefits, having your I.D. picture taken, being sized for and receiving lab coats, obtain hospital computer access and being introduced to various key hospital personnel.

  At orientation, in order to complete the federally mandated I-9 form, you will need to provide verification of work authorization through proof of citizenship or appropriate visa status. If you are not a citizen of the United States you are required to provide us with work authorization documentation (work authorization card, or passport with J1 visa stamp and valid entry stamped DS-2019, or other proof of visa with work authorization).

  BE SURE TO BRING WITH YOU TO ORIENTATION THE FOLLOWING:

a current passport, or
picture driver's license and birth certificate, or
picture driver's license and social security card

Again, please complete all forms and return to Darlene Cushman at the address above. Any forms that require your signature to be witnessed must be signed in person at orientation.