THE VIP PROGRAM

Visiting International/US Orthopedic Surgery Physician’s Program

at NYU LANGONE ORTHOPEDIC HOSPITAL

APPLICATION

Please type information:

Full Name:______

Last or FamilyFirstMiddle

Male or Female:______Date of Birth:______

Current Mailing Address:______

Number & StreetApartment Number

City: ______State: ______Zip: ______Country: ______

Phone: (____) ______Fax: (____) ______

E-Mail Address: ______

Country of Permanent Residency: ______

EMERGENCY CONTACT(S)

Name: ______

Relationship: ______

Address:______

Number & StreetApartment Number

City: ______State: ______Zip: ______Country: ______

Phone: (____) ______Fax: (____) ______

E-Mail Address: ______

Name: ______

Relationship: ______

Address:______

Number & StreetApartment Number

City: ______State: ______Zip: ______Country: ______

Phone: (____) ______Fax: (____) ______

E-Mail Address: ______
MEDICALSCHOOL (OR OTHER)

______

Name of InstitutionDates Attended

______

DegreeDate Awarded

City/State/Country: ______

From:______To: ______

(month/day/year)(month/day/year)

POSTDOCTORAL TRAINING AND EMPLOYMENT

List employment and training experience in chronological order, beginning with the current or most recent institution.

Dates: ______Type of Experience: ______

Institution: ______City/State/Country: ______

From/To:______

(month/day/year)

Identify type: Intern, Residency, Fellowship: ______

Military, Practice, etc: ______

Present Supervisor:______

NameTitle

E-Mail Address: ______

STATEMENT OF INTENT

State your objectives and proposed time period of your visit.

Proposed time period in order of preference: (Observership must be at least one week in duration and cannot exceed 30 days)

FROM:______TO:______

FROM:______TO:______

FROM:______TO:______

Indicate the specific area of orthopedic interest.

(Attach additional sheets as necessary.)

PLEASE NOTE THAT DUE TO HEAVY FACULTY WORKLOADS AND HIGH DEMAND, IT MAY BE DIFFICULT TO OFFER THIS APPOINTMENT TO ALL QUALIFIED APPLICANTS.

TERMS OF APPOINTMENT

Appointments must be at least one week in duration and cannot exceed 30 days

Applicants must be trained in Orthopedic Surgery or are currently in training

Appointments are without compensation, benefits or housing

Visiting Physicians may attend conferences and lectures and are welcome to observe clinical activities but may not participate in the actual deliveryof care. Theydo not perform any healthcare role whatsoever, and are explicitly forbidden to actively participate in patient examinations, procedures, clinical decision making and do not contribute to documentation. Visiting Physician must abide by all applicable HIPAA patient confidentiality regulations. Specific consent must be obtained from any patient whose clinical encounter or procedure will be attended by the Visiting Physician.

This observational experience does not constitute training. Approved Visitors will not receive any form of certification from NYU Langone Orthopedic Hospital for the time of their appointment.

All applicants who are not US citizens or do not have a green card require a WB or B-1 Visa and need to comply with the requirements.

TRANSLATIONS: Documents in a language other than English must be accompanied by a certified translation.

REQUIRED DOCUMENTS

To be submitted at time of filing of application. Only completed applications with appropriate attachments will be considered

Application Form (2nd Attachment)

Professional Letter of Recommendation

Curriculum Vitae

Copy of Medical School Diploma. If the Diploma is in a language other than English, a certified translation must be submitted.

Copy of Current Medical license

Current Photograph and copy of government issued picture ID (license or passport)

NYU Langone Hospitals Center/NYU Langone Orthopedic Hospital: Security Request Form/Academic Observers (5 Page Form)(1st Attachment)

  1. Observer to sign on page 5
  2. Health Assessment Form (Appendix A)

Continue on next page for further requirements

PLEASE NOTE THE FOLLOWING REQUIREMENTS

Up-to-date documentation of vaccines, immunizations, and screenings:

  1. The observer must have received TB screening within the year prior to the observation period.
  2. Acceptable written documentation of immunity to measles, mumps, and rubella:
  3. adequate immunization with live measles, mumps and rubella vaccines
  4. laboratory evidence of immunity
  5. Documentation of a history of varicella, positive (immune) titer, or two varicella vaccinations.
  6. Documentation of effective Hepatitis B immunization (positive immune response), completed hepatitis immunization series, or a signed declination.
  7. Documentation of receipt of influenza vaccine.

Please mail application and attachments to:

Malka Alt

VIP Program

New York University School of Medicine

Department of Orthopedic Surgery

BHC CD 4-81A

New York, New York10016

OR

Scan and email as a PDF file to

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