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TRAINEE APPOINTMENT AND COMPLETION FORMS

• Appointment Letter
• Appointment Letter Request Form (Residents & Fellows)
• Certificate Engrossing Request Form
• Clarian Health-Responsibility Statement Form
• Clarian Hospital Pharmacy Signature Form
• Exit Form for Terminating House Staff
• Extern Appointment Form and Policy
• Health Services Authorization to Medical Release Information Form
• House Staff Information Form
• I-9 form (with instructions)
• I-9 Instructions for F1, J1, H1-B visa status 
• Health Services Form (also known as Resident Immunization Verification Form)
• Jagtag/School of Medicine ID Card Expense Authorization Form
• Motor Vehicle Records Check Form
• Patent Agreement Form
• Temporary and Visiting House Staff Assignment Form
• TB Respirator Questionnaire *for fit testing and TB masks
• Wishard Hospital Pharmacy Signature Form
  
  Background Check Information and Forms
  *Copy of resident/fellow CV requested with forms
• Policies and Procedures for Requesting Background Checks
• Acknowledgement of Receipt of Conditions and Requirements for Appointment
• Background Check Request Cover Sheet
• Consent to Background Check
• Background Check Self-Disclosure Questionnaire
• Statement of Principles-Honor Code
  

BENEFIT FORMS

• Cigna Beneficiary Form (life insurance)
• Anthem Enrollment form (medical after July 1, 2009)
• Anthem application for trainees w/no social security number
• Cigna Dental Enrollment Form
• Domestic Partners Benefits Forms
• Fee Courtesy Form (with instructions)
• Waiver of GME Insurance Coverage

PAYROLL FORMS

• Direct Bank Deposit Form
  *Note: The Payroll Department prefers that direct deposit information be changed electronically via OneStart.  To log into OneStart, click here.  Direct deposit changes can be made in the "Employee Self-Service" menu on the right.
• W-4 Tax Form (Federal)
• WH-4 Tax Form (State)
• W-4 Federal Tax Form for Non-Resident Aliens  
• International Tax Questionnaire (International Medical Grads)

MISCELLANEOUS FORMS

• Authorization for Release of Information
• Leave of Absence Form - Family Medical Leave (FMLA)
• Leave of Absence Form - Standard Leave
• Moonlighting Activity Form
• Paging Equipment Agreement
• Personal Data Change Form
• Personal Profile Form
• Request for IUSM Graduate Student Records

  
  Please submit completed form(s) above to the Office of Graduate Medical Education - Fesler Hall 224.

  
  VAMC Forms

  • Application for Health Professions Trainees
  • Trainee Registration Information for Vista form
    
    
    Please submit completed VAMC form(s) to Alicia Fleener, VAMC Rm. 11E.