FCVS Sample Profile - Federation of State Medical Boards

Transcription

Medical Professional
Information Profile
This report provides credentialing information for
Name: John A. Doe
Social Security Number: XXX-XX-0123
Date of Birth: Month XX, 19XX
FID#: 123456789
Recipient: ST - State Medical Board
ABOUT THIS PROFILE
The Federation Credentials Verification Service (FCVS) was retained by the above referenced medical
professional to verify his/her medical credentials for submission to your agency/organization. Unless
noted otherwise, all documents contained in this report were received directly from the issuing
institution per written request made by FCVS.
NOTICE: All documents bearing an original Official FCVS seal are certified to be an exact reproduction
of the original. Where required, original documents are provided according to the agreements with the
Institution issuing such document. FCVS maintains all original documents (excluding third-party
examination transcripts) in the physician’s source file.
This FCVS medical professional Information Profile (“Profile”) is compiled and provided by the
Federation of State Medical Boards of the United States, Inc. (Federation) as a reference source for,
and only for, its member boards and other entities authorized by the Federation. The Profile embodies
and contains confidential business information because the information, and the format and
presentation of that information, comprise trade secrets of the Federation and because the Profile’s
disclosure would harm the Federation by providing others with an unfair business advantage in
competing with the Federation’s FCVS services. Further, the form of the Profile and the contents of this
Profile, including the compilation of information in this Profile, are the Federation’s copyrighted works
and proprietary, confidential information and are subject to the protections of United States laws
governing copyright, trademark and trade secrets, as well as various state laws protecting the
Federation’s trade secrets and other intellectual property rights. This Profile and its contents may not
be (1) copied, reformatted, modified, published or displayed publicly or (2) used, disclosed, distributed,
shared or sold, in whole or part, for any purpose. including use to establish any database or files as a
compendium or otherwise, all of which is strictly prohibited without the express written consent of the
Federation’s CEO.
© 1996 Federation of State Medical Boards
Note: Your board may wish to review the unresolved items below marked by an "X"
Please review the Credentials Analysis report for further details on the unresolved items
Medical Professional Name:
Date of Birth:
Social Security Number:
FID:
John A. Doe
Month XX, 19XX
XXX-XX-0123
123456789
I. FCVS Reports
II. FSMB and Other Reports
III. Identity
A. Valid Original Passport OR Copy w/ Cert. of Identification
IV. Medical Education
A. Pre-medical Schools
B. Medical Schools
University of State School of Medicine
1. Medical Education Form
2. Medical Education L2
3. Medical Education Dean's Letter
4. Medical Education Transcript
5. Medical Education Diploma
C. Fifth Pathway Program
D. ECFMG Certification
V. Graduate Medical Education
University of State Health Sciences Center, Internal Medicine
1. GME Form
2. GME Completion Certificate
University of State Health Sciences Center, General Surgery
1. GME Form
2. GME Completion Certificate
VI. Licensure Examination History
A. NBME Record of scores
End of report for: John A. Doe
Information Profile
Table of Contents
I. FCVS Reports
_
A. Physician Information Report
B. Credentials Analysis Report
C. Chronology of Activities
II. FSMB and Other Reports
_
A. Board Action Data Bank Report
B. American Board of Medical Specialty Verification
III. Identity
_
A. Affidavit
B. Certified Birth Certificate or Original Passport or Cert. of Identification with Photocopy
C. Documentation to Support Name Variation
IV. Medical Education
_
A. Verification of Medical Education
B. Clinical Clerkships (if applicable)
C. Verification of Fifth Pathway (if applicable)
D. ECFMG Certification (if applicable)
V. Graduate Medical Education
_
A. Verification of Graduate Medical Education
VI. Licensure Examination History (State Licensing Authorities Only)
_
A. LMCC Transcript
B. State Medical Board Transcript
C. NCCPA Transcript
D. NBME Transcript
E. NBOME Transcript
F. FSMB Transcript
Information Profile
Section I
FCVS Reports
Identity
John A. Doe
Documentation: Valid Original Passport OR Copy w/ Cert. of Identification
Gender: Male
Date of Birth: Month XX, 19XX
Place of Birth: ST, UNITED STATES
Social Security Number: XXX-XX-0123
FID: 123456789
Physical Description: Height:
5 ft. 10 in.
Weight:
195 lbs.
Eye Color: Brown
Hair Color: Brown
Contact Information
Mailing Address: 1234 2ND STREET
ANYWHERE, ST 01234
UNITED STATES
Permanent Address: 1234 2ND STREET
ANYWHERE, ST 01234
UNITED STATES
Telephone Numbers: Primary:
Secondary:
(817) 868-4000
Fax:
(817) 868-4099
Other:
N/A
(817) 868-4000
Page 1 of 5
Premedical Education
(Provided by Applicant. Not verified with the primary source.)
Institution: University of ABC
Address: College, ST 12345
UNITED STATES
Dates of Attendance: 09/--/19XX To 06/--/19XX
Degree Conferred/Issued: Applicant did not graduate
(Provided by Applicant. Not verified with the primary source.)
Institution: ABC State University
Address: College, ST 01234
UNITED STATES
Dates of Attendance: 01/--/19XX To 06/--/19XX
Degree Conferred/Issued: Bachelor of Science
ECFMG
There are none identified or not applicable.
Medical Education
Medical School: University of ABC of Medicine
Address: 2500 West Medical Ave
Anywhere, ST 12345
UNITED STATES
Dates of Attendance: 09/XX/19XX to 05/XX/19XX
Date Certificate Issued: 05/XX/19XX
Degree Conferred/Issued: Doctor of Medicine
Unusual Circumstances
Leave of Absence/Extension:
Probation:
Disciplined:
Negative Reports:
Limitations:
No
No
No
No
No
Fifth Pathway
There are none identified or not applicable.
Page 2 of 5
Graduate Medical Education
Institution: University of ABC of Medicine
Address: PO Box 12345
Anywhere, ST 12345
UNITED STATES
Training Level: 1
Program Type: Internship
Specialty: Obstetrics and Gynecology
Dates of Attendance: 07/XX/19XX To 06/XX/19XX
Completed Successfully: Yes
Accreditation: ACGME
Training Level: 2 - 4
Program Type: Residency
Specialty: Obstetrics and Gynecology
Accreditation: ACGME
Probation:
Disciplined:
Negative Reports:
Limitations:
No
No
No
No
No
Page 3 of 5
Institution: University of ABC of Medicine
Address: c/o Department of Obstetrics-Gynecology
PO Box 12345
Anywhere, ST 123456
UNITED STATES
Training Level: N/A
Program Type: Fellowship
Specialty: Maternal Fetal Medicine
Accreditation: None of these
Probation:
Disciplined:
Negative Reports:
Limitations:
No
No
No
No
No
Page 4 of 5
Licensure Examinations
NBME - National Board of Medical Examiners NBME Part I
Date: 06/19XX
Passed the Exam
NBME - National Board of Medical Examiners NBME Part II
Date: 04/19XX
Passed the Exam
NBME - National Board of Medical Examiners NBME Part III
Date: 05/19XX
Passed the Exam
ABMS Verification
A report of the result from a search of the data provided by the American Board of Medical Specialties is enclosed.
Board Action
A report of the results from a search of the Board Action Data Bank is enclosed.
End of report for John A. Doe
Page 5 of 5
FID: 123456789
The Credentials Analysis Report is a comparative report of a medical professional's credentials as reported to FCVS by the
applicant and the primary source (Medical School, PGT program, etc.). It will also list particular missing documentation, if any,
as outlined in the FCVS Policies and Procedures.
Medical Professional Identification
Date of Birth:
FID:
John A. Doe
Month XX, 19XX
XXX-XX-0123
123456789
Omissions
Omission 1:
Section of Profile:
Omission:
Action Taken:
Post Graduate Training
The title of signatory reported by University of ABC of Medicine Department of
Obstetrics and Gynecology on the Verification of Post Graduate Training
Form does not indicate that the signatory is a Doctor of Medicine/Doctor of Osteopathy.
FCVS has determined that the signature on the verification form is the authorized signatory
for this program.
Omission 2:
Section of Profile:
Omission:
University of ABC of Medicine, Maternal Fetal Medicine, did not report
information regarding accreditation on the Verification of Post Graduate Training Form.
Action Taken:
FCVS received a written explanation from the institution regarding the omission. See
comments directly on/or following the Verification of Graduate Medical Education Form.
Omission 3:
Section of Profile:
Omission:
Action Taken:
The title of signatory reported by University of ABC of Medicine, Maternal
Fetal Medicine, on the Verification of Post Graduate Training Form does not indicate that
the signatory is a Doctor of Medicine/Doctor of Osteopathy.
FCVS has determined that the signature on the verification form is the authorized signatory
for this program.
Page 1 of 2
Discrepancies
There are no discrepancies identified.
Miscellaneous Information
There is no miscellaneous information identified.
End of report for: John A. Doe
Page 2 of 2
The Chronology of Activities is a comprehensive report of a medical professional’s activities as reported to FCVS by the medicalprofessional applicant.
Date of Birth:
FID#:
Activity
John A. Doe
Month XX, 19XX
XXX-XX-0123
123456789
Start
Date
End
Date
9/19XX
05/19XX Medical Education University of ABC of
Record
Medicine
Anywhere, ST 12345
UNITED STATES
7/19XX
06/19XX GME Record
University of ABC of Medicine
PO Box 12345
Anywhere, ST 12345
UNITED STATES
7/19XX
06/19XX GME Record
University of ABC of Medicine,
c/o Department of
Obstetrics-Gynecology
Anywhere, ST 12345
UNITED STATES
Location
Overlap Explanation
Program Length Explanation
Information Profile
Section II
FSMB and Other Reports
Board Action
Clearance Report
June XX, 2012
Attn: Tracy Bevers
FCVS
400 Fuller Wiser Rd., #209
Euless, TX 76039
Re: Board Action Query Dated:
FSMB Batch Number:
June XX, 20XX
BQ2100243
June XX, 20XX
The following is a report of the search results from the Board Action Data Bank as of
for practitioners submitted as part of the above-referenced batch for which NO board actions were identified.
Provider cleared with No Actions as of
Name
John A. Doe
June XX, 20XX
DOB
School
Yr/Grad
Provider ID
XX/XX/19XX
012345
19XX
123456
License History
Licensing Entity
STATE
STATE
STATE
PLEASE NOTE: The licensure history information contained in these reports is not considered licensure verification but rather an
indicator of known states of historical licensure for these individuals. Use of this information should be limited to cross-reference
purposes
Page 1 of 1
Page 1 of 1
As of:
06/XX/20XX
John A. Doe
Date of Birth:
XX/XX/19XX
Year of Graduation:
ABMSUID#::
1991 (Doctor of Medicine)
XXX-XX-0123
3456789
Certification
Certification:
Board:
Obstetrics and Gynecology
Specialty:
Status:
Initial Certification:
ACT
11/XX/19XX
Certification:
Board:
Specialty:
Status:
Initial Certification:
Maternal-Fetal Medicine
ACT
04/XX/19XX
All information on the ABMS report is based on a search of data shared with the FSMB by the American Board of Medical
Specialties. For some physicians the biographic data in the ABMS database is incomplete and is not included in the shared data.
FCVS is unable to verify specialty certification on these physicians. FCVS does not follow up with the applicant or ABMS on any
missing or discrepant information.
Information Profile
Section III
Identity
Affidavit and Release
I, the undersigned, hereby certify under oath that I am the person named in this application, that all
statements I have or shall make with respect thereto are true, that I am the original and lawful possessor
and person named in the various forms and credentials furnished or to be furnished with respect to my
application and that all documents, forms or copies thereof furnished or to be furnished with respect to my
application are strictly true in every aspect.
I acknowledge that I have read and understand the “INSTRUCTIONS FOR COMPLETING THE FCVS
APPLICATION” and have answered all questions contained in the application truthfully and completely. I
further acknowledge that failure on my part to answer questions truthfully and completely may lead to me
being prosecuted under appropriate federal and state laws.
Notary:
The physician has
been instructed to
sign the front of the
photograph. Your seal
(or stamp) must be
partly upon the photo
and partly upon the
signature of the
applicant.
I authorize and request every person, hospital, clinic, government agency (local, state, federal or foreign),
court, association, institution or law enforcement agency having custody or control of any documents,
records and other information pertaining to me to furnish to the Federation Credentials Verification
Service any such information, including documents, records regarding charges or complaints filed against
me, formal or informal, pending or closed, or any other pertinent data and to permit the Federation
Credentials Verification Service or any of its agents or representatives to inspect and make copies of
such documents, records, and other information in connection with this application.
I, hereby release, discharge and exonerate the Federation Credentials Verification Service, its agents or
representatives and any person furnishing information, of any and all liability of every nature and kind
arising out of investigation made by the Federation Credentials Verification Service. I authorize the
Federation Credentials Verification Service to release information, material, documents, orders or the like
relating to me or this application to any entity at my request.
John A. Doe
Applicant’s Signature (must be signed in the presence of a notary)
Doe
Applicant’s Printed Last Name
John A.
Applicant’s Printed First Name, Middle Initial, and Suffix (e.g., Jr.)
9/28/2011
Date of Signature (must correspond to date of notarization)
State of Texas
, County of
Lubbock
,
I certify that on the date set forth below the individual named above did appear personally before me and that I did identify this applicant by: (a)
comparing his/her physical appearance with the photograph on the identifying document presented by the applicant and with the photograph
affixed hereto, and (b) comparing the applicant’s signature made in my presence on this form with the signature on his/her identifying document.
th
The statements on this document are subscribed and sworn to before me by the applicant on this 28
day of Sept
, 2011
.
Notary Public Signature:
Jane I. Sanotary
My Notary Commission Expires:
123456
123456
10/24/2012
123456789
CERTIFICATION OF IDENTIFICATION
Certification by Notary Public Is Required
Applicant Full Legal Name:
FCVS ID Number:
Doe
John
Last
A.
First
Middle
123456
Notary – Please complete the section below:
State of
Texas
County of
Lubbock
I certify that on the date set forth below, the individual named above, did appear personally before me
and presented one of the following forms of identification as proof of his/her identity (Birth Certificate
or Passport). I further certify that I did identify this applicant by comparing his/her physical appearance
with the photograph on a Government issued photo identification presented by the applicant.
The statements on this document are subscribed and sworn to before me by the applicant on this
(Day) 28th
, of (Month) September
,(Year)
2011
.
Notary Public Signature:___Jane I. Sanotary______________________________
Commission Expiration Date* (Month)
10
/(Day) 24
/(Year)
2022
* The notary’s commission expiration date must be current and legible. If no expiration
date, such as ‘lifetime’, an explanation must be provided.
Notary Stamp Here
Please complete and mail this original document and a photocopy of the birth certificate or passport
presented to the Notary to:
Federation of State Medical Boards
ATTN: FCVS
400 Fuller Wiser Rd., Suite 300
Euless, TX 76039-3856
Signature
Information Profile
Section IV
Medical Education
Verification of
Medical Education
Page 1 of 2
Instructions to the Dean
Please complete both
pages of this form, sign,
date and seal on the front
page then return to:
Federation Credentials
Verification Service
Suite 300
400 Fuller Wiser Road
Euless, TX 76039
or e-mail to:
[email protected]
Institution Name:
The individual identified on the attached Authorization for Release of Information, Documents and Records
form has authorized your medical school to provide to the Federation Credentials Verification Service (FCVS)
any and all information pertaining to their education at your institution.
Please note: If your institution processes transcript requests through another office, FCVS has likely made such a
request under separate cover.
If your office also processes transcript requests, please attach the individual's official transcript
(which indicates courses taken, dates and hours of attendance, and scores, grades, or evaluation).
Address Line 1: 2500 West Medical Ave
Address Line 2:
City: Anywhere
State/Province: ST
ZIP Code (postal code): 12345
Country: US
If name of institution was different when this individual attended, please note this name below:
Premedical Education:
Years of education required for admission to your medical school:
4 years with a bachelor’s degree.
Bachelors degree
Credential/degree presented by the applicant for admission to your medical school:
Enrollment and Participation: Our records indicate that
Doe, Joe A.
attended our
(type/print individual's name: Last, First, Middle, Suffix)
medical school for a total of 158 weeks of medical education on the following dates:
From 9
/26 / 1983
Month Date Year
To 5
Month
/ 23
/ 1987
Date
Year
This individual:
Was awarded the degree of
MD
on 5 /
23
/
1987
Month Date
Was NOT awarded a degree because: (please explain — attach additional pages if necessary)
Attestation
Watermark
For FCVS internal use only.
Print Name:
Affix Institutional
Seal Here.
_________________
If no seal is available,
this form must
be notarized.
Signature:
Title:
Tel:
Date:
Fax:
E-mail:
/
/
Year
Verification of Medical Education
Page 2 of 2
1. Do this individual's official records reflect (an) interruption(s) or extension(s) in
medical education?
e his/her
notarized
YES
NO X
If YES, please select the reason(s) for, indicate the dates of the interruption(s) or extension(s) and check whether the Interruption/extension
was approved or unapproved.
Personal/Family
From (Mo /Yr)
/
To
(Mo /Yr)
/
Approved
Unapproved
Academic remediation
From (Mo /Yr)
/
To
Health
From (Mo /Yr)
/
To
(Mo /Yr)
/
Approved
Unapproved
(Mo /Yr)
/
Approved
Financial
From (Mo /Yr)
/
Unapproved
To
(Mo /Yr)
/
Approved
Unapproved
Participation in joint degree
Program (e.g., MD/PhD)
From (Mo /Yr)
/
To
(Mo /Yr)
/
Approved
Unapproved
Participation in non-research special study
(e.g., fellowship, international experience)
Participation in non-degree research
From (Mo /Yr)
/
To
(Mo /Yr)
/
Approved
Unapproved
From (Mo /Yr)
/
To
(Mo /Yr)
/
Approved
Unapproved
Other
From (Mo /Yr)
/
To
(Mo /Yr)
/
Approved
Unapproved
Other
From (Mo /Yr)
/
To
(Mo /Yr)
/
Approved
Unapproved
Please Specify:
2. Do this individual's official records reflect that he/she was ever placed on academic or disciplinary
probation during his/her medical education?
If YES, please select the reason(s) for the probation, indicate the date(s) of placement on and removal
from probation and attach additional documentation to this report.
YES
NO X
3. Do this individual's official records reflect that he/she was ever disciplined for unprofessional
conduct/behavioral reasons by the medical school or parent university?
If YES, please provide detailed documentation/information about the circumstances and outcome(s):
YES
NO X
4. Do this individual's official records reflect that he/she was ever the subject of negative reports for
behavioral reasons or an investigation by the medical school or parent university?
If YES, please provide detailed documentation/information about the circumstances and outcome(s):
YES
NO X
Academic Probation
From (Mo /Yr)
/
To
(Mo /Yr)
/
Probation for unprofessional conduct/behavioral
From (Mo /Yr)
/
To
(Mo /Yr)
/
Probation for other reason
From (Mo /Yr)
/
To
(Mo /Yr)
/
Please specify reason:
5. Do this individual's official records reflect that there were any limitations or special requirements
imposed on the individual because of questions of academic incompetence, disciplinary problems,
or any other reason?
YES
If YES, please provide detailed documentation/information about the nature of the limitations or special requirements.
NO X
Page 1 of 1
Medical School
John A. Doe
Did you have any interruption(s) or extension(s) in your medical education?
Yes
No
Were you ever placed on probation?
Yes
No
Were you ever disciplined or placed under investigation?
Yes
No
Were any negative reports for behavioral reasons ever filed by instructors?
Yes
No
Yes
No
Were any limitations or special requirements imposed on you because of
academic performance, incompetence, disciplinary problems or for
any other reason?
President
Chief Academic Office
Signature
Signature
Granted at the University of ABC of Medicine on this tenth day of May, two thousand and twelve.
with all the rights, priveleges and honors appertaining therto.
In Witness Wherof the Seal of the University is hereto affixed.
Bachelor/Masters of Science in Biology/Medicine
has completed all the requirements for Graduation, now, therefore, We, under
the authority vested in us by law and on recommendation of the University Facult,
do herby confer the degree of
John A. Doe
to all to whom these presents may come, Greeting: Whereas
The University of ABC of MEDICINE
of
The President and Faculty
Information Profile
Section V
Verification of
Institution Name: University of ABC of Medicine
Address Line 2:
City:
Anywhere
Country:
State/Province:
USA
ST
Zip Code (postal code):
Affiliated University:
University of ABC
12345
Institution name if different when individual attended:
Verification For:
John A. Doe
Date of Birth:
Month XX, 19XX
Individual's Name on Record (If different from above):
Program
Participation
Important:
Report Incomplete
Training Levels (years)
separate from those that
were successfully
completed.
__________________
If the training level (year)
is currently in progress,
report the expected
completion date in the
"To" field.
__________________
Report Internships,
Residencies and
Fellowships separately.
__________________
Use one section per
Department/Specialty.
If the Department or
Specialty is rotating or
transitional, please
provide a schedule
of rotations.
Unusual
Circumstances
Program Type
Training Level: 1
Specialty/Subspecialty:
OBYGN
X Internship
(e.g., 1, 2, 3, etc.)
Residency
Chief Residency From: 07 / 01/ 1987
To: 06
/30
/1998
Fellowship
Research
Successfully Completed?: X Yes
No
In Progress If no, was credit awarded Yes
No
Accredited by:
AOA
LCGME
RSC
CFPC
RCPSC
APPAP
None of these
Not accredited
X ACGME
Program Type
Training Level: 2, 3, 4
OBYGN
Internship
(e.g., 1, 2, 3, etc.)
X Residency
Chief Residency From: 07 / 01
/ 1988
To: 06 / 30
/ 1991
Fellowship
Research
No
No
Accredited by:
AOA
LCGME
RSC
CFPC
RCPSC
APPAP
None of these
Not accredited
X ACGME
Program Type
Training Level:
Internship
(e.g., 1, 2, 3, etc.)
Residency
Chief Residency From:
/
/
To:
/
/
Fellowship
Research
Successfully Completed?: Yes
No
No
Accredited by:
ACGME
AOA
LCGME
RSC
CFPC
RCPSC
APPAP
None of these
Not accredited
1. Did this individual ever take a leave of absence or extension from his/her training?
Yes
X No
If “Yes” provide start and end date _________/_________
Check the correct
response. Omitted
responses require
written explanation.
__________________
If necessary, continue
your explanation on a
separate sheet of paper.
2. Was this individual ever placed on probation? …………………………………………………………
Yes
X No
3. Was this individual ever disciplined or placed under investigation? ………………………………….
Yes
X No
4. Were any negative reports for behavioral reasons ever filed by instructors? ...……………………..
Yes
X No
Yes
X No
Attestation
Watermark
5. Were any limitations or special requirements placed upon this individual because
Affix Institutional
Seal Here.
_________________
this form must
be notarized.
of questions of academic incompetence, disciplinary problems or any other reason? ……..……..
Please explain any "Yes" response from above:
Completion attests the information above is an accurate account of this individual’s records and is true and correct.
Signature line must contain original signature or electronic typed signature of program director (M.D./D.O. ONLY –
PLEASE REPORT WHICH ).
Print Name:
First Last Name
Signature:
First Last Name
Title:
Program Manager
Tel: 817-868-4000
MD/DO:
Date:
Fax:
817-868-4009
E-mail:
03 / 15
/ 2012
[email protected]
Page 1 of 1
John A. Doe
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
any other reason?
President
Signature
Signature
John A. Doe
of
Verification of
Institution Name: University of ABC of Medicine
Address Line 2:
City:
Anywhere
Country:
State/Province:
USA
ST
Zip Code (postal code):
Affiliated University:
University of ABC
12345
Institution name if different when individual attended:
Verification For:
John A. Doe
Date of Birth:
Month XX, 19XX
Individual's Name on Record (If different from above):
Program
Participation
Important:
Report Incomplete
Training Levels (years)
separate from those that
were successfully
completed.
__________________
If the training level (year)
is currently in progress,
report the expected
completion date in the
"To" field.
__________________
Report Internships,
Residencies and
Fellowships separately.
__________________
Use one section per
Department/Specialty.
If the Department or
Specialty is rotating or
transitional, please
provide a schedule
of rotations.
Unusual
Circumstances
Program Type
Training Level: 1
OBYGN
X Internship
(e.g., 1, 2, 3, etc.)
Residency
Chief Residency From: 07 / 01/ 1987
To: 06
/30
/1998
Fellowship
Research
No
No
Accredited by:
AOA
LCGME
RSC
CFPC
RCPSC
APPAP
None of these
Not accredited
X ACGME
Program Type
Training Level: 2, 3, 4
OBYGN
Internship
(e.g., 1, 2, 3, etc.)
X Residency
Chief Residency From: 07 / 01
/ 1988
To: 06 / 30
/ 1991
Fellowship
Research
No
No
Accredited by:
AOA
LCGME
RSC
CFPC
RCPSC
APPAP
None of these
Not accredited
X ACGME
Program Type
Training Level:
Internship
(e.g., 1, 2, 3, etc.)
Residency
Chief Residency From:
/
/
To:
/
/
Fellowship
Research
Successfully Completed?: Yes
No
No
Accredited by:
ACGME
AOA
LCGME
RSC
CFPC
RCPSC
APPAP
None of these
Not accredited
1. Did this individual ever take a leave of absence or extension from his/her training?
Yes
X No
If “Yes” provide start and end date _________/_________
Check the correct
response. Omitted
responses require
written explanation.
__________________
If necessary, continue
your explanation on a
separate sheet of paper.
2. Was this individual ever placed on probation? …………………………………………………………
Yes
X No
3. Was this individual ever disciplined or placed under investigation? ………………………………….
Yes
X No
4. Were any negative reports for behavioral reasons ever filed by instructors? ...……………………..
Yes
X No
Yes
X No
Attestation
Watermark
5. Were any limitations or special requirements placed upon this individual because
Affix Institutional
Seal Here.
_________________
this form must
be notarized.
of questions of academic incompetence, disciplinary problems or any other reason? ……..……..
Please explain any "Yes" response from above:
Completion attests the information above is an accurate account of this individual’s records and is true and correct.
Signature line must contain original signature or electronic typed signature of program director (M.D./D.O. ONLY –
PLEASE REPORT WHICH ).
Print Name:
First Last Name
Signature:
First Last Name
Title:
Program Manager
Tel: 817-868-4000
MD/DO:
Date:
Fax:
817-868-4009
E-mail:
03 / 15
/ 2012
[email protected]
Page 1 of 1
John A. Doe
Maternal Fetal Medicine
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
any other reason?
President
Signature
Signature
John A. Doe
of
Information Profile
Section VI
Licensure Examination History
(State Licensing Authorities Only)

FCVS Sample Profile - Federation of State Medical Boards

Transcription

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