FORMS 

PROGRAM FORMS

  • CEX are now done through MedHub, you may self initiate one (Prelims must contact Jefferson to queue up this evaluation).
  • Preceptor & Resident Self-Evaluation
  • Continuity Clinic forms
  • M&M conferences are attendance based. You must attend 2 per year, there is no form requirement for M&Ms
  • Out-of-State Elective Request Form
  • Please submit the Out of State Elective Request form to the Housestaff office. 
  • PC Research Approval Form
  • Preceptorship or Special Rotations Request Form
  • Research Approval Form
  • Request for Travel Funds Form  - If a Resident has been invited to present at a meeting or conference, it is expected that a research grant of the resident's faculty sponsor will cover the resident's expenses. The next source of funding is a grant of $1500 from the GME Educational Fund allowance. To receive this funding, please provide a copy of the invitation to present along with this form to Jefferson.Velasco@cuanschutz.edu. In order to be reimbursed, travel arrangements must be made through our office. 
    • Airfare MUST be booked through Jefferson per procurement policy.
    • Please note that as of June 12, 2020 there is a system wide travel ban until January 2021. Amount of funding from GME is subject to change at this time. This information will be updated as soon as it is available.

POLICY FORMS

MOST COMMONLY USED FORMS:

  • DORA L3 R3 Training Verification 17-18.pdf - Please fill out SECTION ONE of this form and submit hard copy to Jennifer Weber in the Housestaff office for completion. A request for proof of malpractice insurance will be sent on your behalf. 
  • DORA (L6) Practice History​ - This form is prefilled for you.  Print, sign and add to your application. 
 

Please visit https://www.fsmb.org/step-3/​ for more information on how to apply for the USMLE Step 3 exam. 

The Certification of Identity form is the only form now needed
The application process to sign up and take step 3 has changed:
“To apply for the Step 3 all physicians are required to create an account, complete the online application, and pay the fees. Once the application is submitted, all that is needed to complete the Step 3 application is the Certification of Identity form (http://www.fsmb.org/Media/Default/PDF/USMLE/USMLEStep3_Certification_of_identity.pdf).
 
[NOTE: The Certification of Post Graduate Training form is no longer needed.]
If you are not contacted about your application within ten business days, contact the FSMB office (usmle@fsmb.org) to determine your application status. They will only provide the status information to the you, the physician, and not a third party.  Please submit USMLE Certificate of Identity form (hard copies) to Mary Meadows or Nicole Goodwin in the Housestaff office to notarize. ( example copy)