International Rotation Agreement

Page 1

International Mission TripResident/Fellow Rotation

Resident/Fellow: Department:

Dates of Rotation:

The following is a checklist of items GME needs before a resident/fellow can leave on an International Resident/Fellow Rotation. Please check each box when the responsibilities are compliant.

The completed packet should be delivered to GME at 1140 Delp, Mail Stop 1060 at least two weeks prior to the International Mission Trip rotation.

KUMC Coordinator Responsibilities:

☐Complete a Memorandum of Agreement for the International resident/fellow rotation, and then circulate for all signatures. Include Attachments A, BC, DandE.

☐Attachment A- Training Site Director and Faculty

☐Attachment B- Rotation Goals and Objectives

☐Attachment C- Preceptor’s Curriculum Vitaeand Letter to KU Program Director

☐Attachment D- Director of International Programs paperwork of completion

☐Attachment E- Temporary License in the State/Country of Training Site

☐Notify Graduate Medical Education(8-3217) of an International Rotation at least two months in advance.

☐Contact KUMC Travel Audit (8-5348) at least two months in advance to have a travel request approved so that the resident/fellow will be covered by Worker’s Compensation during the rotation.

☐Request a preceptor letterwritten to the KU Program Director approving the rotation. The letter should include the resident’s/fellow’s name, the name of the foreign institution, and the dates of the rotation.

☐Complete a New Service Request form (if not currently in MedHub)

☐Schedule resident/fellow into Mission TripService in MedHub

Program Coordinator’s Signature:______

KUMC Program Director Responsibilities:

☐Speak directly with international preceptor by telephone at least two months before the planned rotation to ensure all parties agree that the rotation should occur.

☐KUProgram Director has a signed letter of approval from the international rotation Program Director.

☐Resident understands professional licensure requirements for the international rotation.

Program Director agrees to allow this resident to complete an international rotation as a part of their residency/fellowship training program.

Program Director’s Signature:______

KUMC Resident/Fellow Responsibilities:

☐Submit the preceptor’s Curriculum Vitae (Attachment C) to your Program Coordinator as soon as possible.

☐Contact theDirector of International Programs, at least six months in advance. Schedule an appointment to complete the required paperwork and Attachment D.

☐Once the International Mission Trip rotation has been approved, contacta Travel Immunization Clinic (see attached for nearby clinics),to receive a list of shots required by the foreign country. A signature is required.

Travel Clinic Representative’s Signature:______

☐Contact Payroll to ensure your stipend will be placed in a bank account that is accessible to you.

☐Check to see if your medical license will expire while you are on rotation in the foreign country.

☐Reason for Mission Trip:______MISSON______

Resident’s/Fellow’s Signature:______

New Service Request (MedHub)

Each Service needs its own form

Date:

Please complete the following information:

Department:

Requested by:

Resident/Fellow Name:

Rotation Start Date and End Date:

Training Site:

State/Country:

Zip Code:

Service Type:

(choose one) ☐Inpatient care

☐Outpatient care

☐Mixed

☐Non-Patient Care/Other

GME Office Use Only:

Service Name:______

Site:______

Date Added to MedHub:______

______signed off by GME Assistant Dean

______signed off by Senior Administrative Coordinator

Travel Immunization Clinic Locations

Johnson County Health Dept
11875 South Sunset
Ste 300
Olathe, KS 66061
913-894-2525 website / Olathe, KS / Johnson County
Hen House Pharmacy
13600 S. Blackbob
Olathe, KS 66062
913-782-2039 / Olathe, KS / Johnson County
Johnson County Health Dept
6000 Lamar Ave
Rm 140
Mission, KS 66202
913-826-1200 website / Mission, KS / Johnson County
Ward Parkway Health Services
8800 State Line
Leawood, KS 66206
913-383-9099 / Leawood, KS / Johnson County
Travel and Immunization Clinic Dr. Stephen Scherer, MD, Owner and Medical Director
4550 West 109th St
Ste 170
Overland Park, KS 66211
913-469-0011 website / Overland Park, KS / Johnson County
Debbie WalkerExecutive Director
Passport Health
8249 West 95th Street, Suite 105
Overland Park, KS 66212
Tel: 913-652-6640
Fax: 913-652-6645

The University of Kansas Medical Center

MEMORANDUM OF AGREEMENT

BETWEEN

UNIVERSITY OF KANSAS MEDICAL CENTER, KANSAS CITY, KS

UNIVERSITY OF KANSASSCHOOL OF MEDICINE

AND

[Training Site Name]

<Date>

The University of Kansas Medical Center (herein referred to as “University”), the University of Kansas School of Medicine, and the [University of ???????, Division of ???????] (herein referred to as “Training Site”) in the state of [??????? State] entered into this Agreement as of [????????? Date ].

NOW THEREFORE, in consideration of the premises herein contained, the parties agree as follows:

This memorandum of agreement covers the following areas as required by the ACGME:

  1. Intent: This agreement approves an Mission Trip rotation for <Resident Name, Degree>, a resident in the KUMC Department Name> residency training program at the University, for the duration of <Start Date> to <End Date>.The rotation will consist of an educational experience intended to broaden the resident’s management and experience in providing quality patient care.
  1. Faculty: The faculty who will assume both educational and supervisory responsibility for residents/fellows at the training site are listed in ATTACHMENT A. The faculty is under the directorship of the Training Site Director <Training Site Director>and the University of Kansas School of Medicine Program Director <KUMC Program Director>. The Training Site director is responsible for providing adequate supervision and education of the residents during the course of their educational experience at the Training Site in collaboration with the program director, as embodied by both KUMC Graduate Medical Education Policy and Procedure Manual, and the Training Site department’s staff policies.
  2. Faculty Responsibilities: The Training Site faculty must provide appropriate supervision of residents/fellows in patient care activities and maintain a learning environment conducive to education of the residents in the ACGME Competency areas. The faculty must evaluate resident performance in a timely manner during each rotation or similar educational assignment and document this evaluation at the completion of the assignment. Evaluations are to be sent to the KUMC Program Director. The Training Site Director is responsible for informing the Program Director of the residents’ performance during the rotation and for notifying the Program Director in a timely manner of any difficulties or deficiencies in the resident’s performance.
  3. Content: The content of the educational experience has been developed according to ACGME Program Requirements and include the Rotation Goals and Objectives found in ATTACHMENT B. In cooperation with the KUMC Program Director, the Training Site Director and Faculty are responsible for the day-to-day activities of the residents/fellows to ensure that the goals and objectives are met during the course of the educational experience at the Training Site.
5.Evaluation of Residents: Upon completion of the Mission Trip rotation, the Training Site shall provide the resident’s Program Director with an evaluation of the resident’s performance.
  1. Fiscal Considerations: Residents who participate in the rotation at the Training Site are not considered employees of the Training Site, and are not entitled to receive from Training Site monetary compensation, worker’s compensation insurance, and /or any other employee benefits or status. Resident stipend shall be paid by the University of Kansas School of Medicine, and otherwise, no party shall make financial contributions to the other related to the Agreement.
  2. Licensure: Residents rotating to the Training Site will have a valid permanent or temporary Kansas medical license, when applicable, a valid temporary license in State/Countryof Training Site.
  3. By Laws, Rules, and Departmental Regulations: University residents rotating to the Training Site shall agree to observe faithfully the medical staff bylaws of the Training Site and agree to be bound by its terms.
  4. Liability Insurance: University will provide full professional liability coverage for each resident rotating to the Training Site. This coverage shall be through the University’s self-insurance program established in Kansas Statutes Annotated §40-3401, etseq.
  5. General: Neither the Training Site nor the University shall discriminate against any resident participating in the program at the Training Site on the basis of race, color, age, religious affiliation, gender, national origin, sexual orientation or disability.
  6. Policies and Procedures: The policies and procedures that govern resident/fellow education are outlined in the KUMC Graduate Medical Education Policy and Procedure manual ( the ACGME Policy and Procedure Manual, as well as the Training Site GME Policy Manual. Any potential disciplinary action will follow the guidelines specified in the KUMC GME Policy and Procedure Manual.

We value and appreciate our educational rotation with you.

Notices required herein shall be sent to:

For the University:For the Training Site:

<Institutional Official/Program Director Name>, M.D.

Associate Dean for Graduate Medical Education <Title

University of Kansas Medical Center <Department

Mailstop 1060 <Address

3901 Rainbow Boulevard <City, State/Country, Zip

Kansas City, KS 66160-7301

With a copy to:

Office of Legal Counsel

3901 Rainbow Boulevard

Kansas City, KS 66160-7101

Signature Page

University of Kansas Medical center <Training Site>

______

Resident/Fellow SignatureDate <Program Director Name>, <degree>Date

Program Director-<Department Name>

______

<Program Director Name>, <degree>Date <Institutional Official Name>, <degree>Date

Program Director-<Department Name> Institutional Official-<Department Name>

University of KansasMedicalCenter

The Graduate Medical Education Office will complete these signatures:

Executive Dean, School of Medicine Date

University of Kansas Medical Center

Approved as to form:

Associate Dean for Graduate Medical Education Date

University of Kansas Medical Center

ATTACHMENT A

<Training Site>

TRAINING SITE DIRECTOR AND FACULTY

<Training Site Director>

<Training Site Faculty>

ATTACHMENT B

<Training Site>

ROTATION GOALS AND OBJECTIVES

ATTACHMENT C

<Training Site>

PRECEPTOR’S CURRICULUM VITAEandLetter to KU Program Director

ATTACHMENT D

<Training Site>

Director of international programs Signature of paperwork completion

<Resident Name, Degree> in the department of < Department Name> has completed the following requirements and submitted the paperwork for an International Mission Trip Rotation in<Training Site>.

HEALTH AND SAFETY AND CULTURE REQUIERMENTS

  1. Explore culture and developing your cross-cultural competence by attending The Culture Hour, every Thursday, 12-12:45 in the Calkins Conference Room G005 Orr Major (mandatory attendance at 3 meetings prior to traveling abroad)
  2. Attend one required Health and Safety Meeting
  3. Read the Travel Tips specific to your educational experience destination
  4. Read the PRE-DEPARTURE SUGGESTIONS
  5. Read the PROBLEM SOLVERS
  6. Read and travel with the SAFETY ABROAD BROCHURE
  7. Register with Smart Traveler Enrollment Program (STEP) at
  8. Sign and submit the Waiver of Liability form
  9. Discuss insurance requirements with International Programs and submit Health Insurance information; or complete the Lewer Agency Health Insurance form and submit $25 fee to the Office of International Programs

** If you are traveling back to your native country, you are exempt from requirements 1-6. If you are NOT a US citizen or US national, you are exempt from number 7 **

REQUIRED PAPERWORK

  1. Color copy of your passport
  2. Color copy of your VISA (if applicable)
  3. Flight and travel itinerary
  4. Emergency Contact Form
  5. Waiver of Liability
  6. STEP enrollment confirmation

University of Kansas Medical center

<Resident Name, Degree>Date

Director of International Programs Date

ATTACHMENT E

<Training Site>

TEMPORARY LICENSE FROM STATE/COUNTRY FROM TRAINING SITE

Revised 8/22/2014

KUMC Legal Review: 10/20/2009