ADULT ACGME Accredited CARDIOTHORACIC … Accredited Fellowship Program Department of Anesthesiology...

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ADULT CARDIOTHORACIC ANESTHESIOLOGY FELLOWSHIP PROGRAM VANDERBILT MEDICAL CENTER UNIVERSITY ACGME Accredited Fellowship Program Department of Anesthesiology Vanderbilt University Medical Center Division of Cardiothoracic Anesthesiology www.vandydreamteam.com

Transcript of ADULT ACGME Accredited CARDIOTHORACIC … Accredited Fellowship Program Department of Anesthesiology...

ADULTCARDIOTHORACICANESTHESIOLOGY

FELLOWSHIPPROGRAM

VANDERBILT

MEDICAL CENTER

U N I V E R S I T Y

ACGME AccreditedFellowship Program

Department of AnesthesiologyVanderbilt University Medical Center

Division of Cardiothoracic Anesthesiologywww.vandydreamteam.com

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Table of Contents 2

Introduction 3

Program Goals 4

Clinical Program Overview 5-6

TEE Simulation 7

Key Faculty 8

Application Guidelines 9-11

Adult Cardiothoracic AnesthesiaFellowship Program Application 12-20

Contact Us! 21

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The Vanderbilt Adult Cardiothoracic Anesthesia Fellowship Program is committed to providing the highest quality training for future leaders, educators, and practitioners of cardiothoracic anesthesia. We offer a breadth of clinical experience including, but not limited to:

On-pump coronary artery bypass•Off-pump coronary artery bypass•Valve surgery•Minimally invasive surgery•Aortic surgery•Thoracic surgery•Airway reconstruction and management•Heart and lung transplant•Ventricular assist device placement•and hybrid operating room procedures pioneered at Vanderbilt. •

Our program is ACGME-accredited, and we have three one-year positions available annually. For our large clinical volume, the number of fellows in the program is relatively small which allows the opportunity for a personalized, tailored educational experience for each fellow. Our fellows arrive to the Vanderbilt campus with varying backgrounds but with the common qualities of academic achievement, intellectual curiosity, compassion, and a strong work ethic. Although the fellowship is primarily clinical, fellows are required to complete at least one academic project with a faculty mentor during their fellowship year.

For fellow candidates interested in a more intensive research experience, we also offer a Cardiothoracic Anesthesia and Clinical Pharmacology Fellowship Track supported jointly by the Divisions of Cardiothoracic Anesthesiology and of Clinical Pharmacology. This involves a minimum 2-year commitment. The first year consists of clinical training in full compliance with ACGME requirements for fellowship training in cardiothoracic anesthesiology. The second year is dedicated to research under the mentorship of a faculty member of the Clinical Pharmacology Division, the largest and one of the most successful divisions of its kind in the world. During this advanced research program, fellows would simultaneously pursue a Master of Science in Clinical Investigation (MSCI), a Master’s program specifically designed to pair young investigators with established mentors and provide coursework in statistical analysis and clinical trial design. Trainees with interest in this academic path may also apply after their clinical fellowship year. There is a very strong history of collaboration between the Division of Cardiothoracic Anesthesiology and the Division of Clinical Pharmacology.

There are also clinical two-year fellowship options for fellows who wish to pursue additional subspecialty training and/or certification in critical care, pain, or pediatric cardiac anesthesiology.

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LS The goal of the Cardiothoracic Anesthesia Fellowshipis to provide a comprehensive, progressive, subspecialized program of study for cardiothoracic anesthesia fellows as outlined by the six ACGME competencies of

patient care•medical knowledge•practice based learning and improvement•systems based practice•professionalism•

andinterpersonal and communication skills. •

For successful completion of the fellowship, the fellow must demonstrate excellence in all six competencies.

At the completion of the fellowship, the fellow is expected to be an expert consultant in the field of cardiothoracic anesthesia while always maintaining the highest standards of care and stewardship for his/her patients.

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The clinical program follows the course of study outlined by the ACGME Adult Cardiothoracic Anesthesia Fellowship criteria.

Adult cardiothoracic rotation(7 months)At least two days per week the fellow will conduct the anesthetic of a complex cardiac case (including performance of a complete TEE exam) under the direct supervision of the attending. As part of a program of graduated responsibility, up to three days per week can be devoted to teaching/supervision of residents in cardiac cases, formulating the anesthetic plan with the resident and attending, and performing TEE exams. The fellow is assigned to the cardiac catheterization lab/electrophysiology lab/hybrid operating room 4-6 days/month, caring for patients undergoing hybrid procedures (combined cardiac surgery and interventional cardiology), electrophysiology procedures (EP studies, pacemaker/ICD placement), and interventional cardiology procedures (tandem heart placement, cardiac catheterization/intervention, device closure of septal defects). Preoperative assessment and postoperative follow-up are required components of this rotation.

Cardiovascular intensive care unit rotation(1 month)The fellow spends a month in the cardiovascular ICU under the supervision of cardiothoracic and critical care anesthesiologists. The fellow will be responsible for the comprehensive management of critically ill cardiovascular and thoracic patients. The cardiovascular ICU is dedicated to the care of cardiovascular and thoracic patients.

Adult thoracic anesthesia rotation(1 month)Fellows spend 4-5 days per week caring for patients undergoing thoracic surgery. In at least 40% of the cases, the fellow conducts the anesthetic management of the patients under the direct supervision of the attending. The fellow has resident supervisory/educational responsibilities for the remaining cases.

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Pediatric cardiothoracic anesthesia rotation (1 month)Fellows are the primary anesthesia provider for pediatric cardiac surgery patients under the direct supervision of the attending. Pediatric cardiac areas include operating rooms, a catheterization lab, and an electrophysiology lab.

Cardiology rotation elective(1 month)Four weeks are spent in the subspecialty of echocardiography under the supervision of adult echocardiography cardiologists. During the rotation, the fellow continues to develop skills in performance and interpretation of transesophageal echocardiography as well as transthoracic echocardiography. He/she is required to attend all cardiology conferences during that month.

Elective rotation (2 months) Typically one of the two elective months is a cardiology rotation, but other clinical or research electives pertaining to cardiothoracic anesthesia may be substituted with permission of the Program Director.C

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Fellows are encouraged to attend and submit presentations to local, regional, and national cardiothoracic meetings. They are given a Continuing Medical Education (CME) budget of over $2000.00 to help defray the expenses of a conference. Each fellow can submit a proposal for one week of academic leave to attend a conference/meeting.

All graduating fellows will meet clinical requirements forboardcertificationinPerioperativeTransesophagealEchocardiographyandmayapplyforboardcertificationaftersuccessfullypassingthePTEeXAM.

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LAof Vanderbilt University School of Medicine opened its doors in August of 2007 after three years of planning and construction. The Center is a result of a shared vision that brings simulation education to the forefront of Vanderbilt medical education and positions the School of Medicine to be a national leader in transforming medical education.

The Center for Experiential Learning and Assessment (CELA) provides an educationally rich environment in which to train healthcare professionals in the practice of safe, effective, efficient and compassionate clinical care. The facility is a state-of-the-art simulation center in technology, space design, physical and organizational integration as well as audiovisual capabilities.

Within CELA, the Simulations Technologies Program is housed in 4500+ sq. ft. on the third floor of MRB IV (3450 MRB IV). It incorporates a virtual reality/partial task trainer room, which is available 24/7 under card swipe access, and is equipped with the latest in virtual reality simulators and partial task trainers designed to train advanced medical procedures.

Cardiothoracic fellows will receive image acquisition training on the high fidelity Heartworks TEE simulators in CELA. The simulators demonstrate cardiac anatomy and the complex spatial relationships involved in TEE imaging with impressive clarity. Experience with the TEE simulator allows fellows to rapidly master basic imaging anatomy in order to progress to more advanced aspects of the TEE exam.

The Center for Experiential Learningand Assessment (CELA)

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LTY Annemarie Thompson, MD

Associate Professor Anesthesiology and MedicineDepartments of Anesthesiology and Internal MedicineProgram Director, Adult Cardiothoracic Anesthesiology Fellowship ProgramDivision of Cardiovascular AnesthesiologyVanderbilt University School of Medicine

Robert J. Deegan, MB, BCh, BAO, PhD, FFARCSIAssociate Professor of Clinical AnesthesiologyDirector, Division of Cardiothoracic AnesthesiologyDirector of Intraoperative EchocardiographyMedical Director II, OR Cardiac ServicesDivision of Cardiovascular Anesthesiology Vanderbilt University School of Medicine

Susan S. Eagle, MDAssociate Professor of Clinical AnesthesiologyAssistant Director, Thoracic AnesthesiologyDivision of Cardiovascular Anesthesiology Vanderbilt University School of Medicine

Julian S. Bick, MDAssistant Professor of Anesthesiology Division of Cardiovascular AnesthesiologyDepartment of Anesthesiology Vanderbilt University School of Medicine

Antonio Hernandez, MDAssistant Professor of Anesthesiology Division of Cardiovascular AnesthesiologyDepartment of Anesthesiology Vanderbilt University School of Medicine

Chad Wagner, MDAssociate Professor of Clinical AnesthesiologyMedical Director CVICUMedical Director CVICU Nurse PractitionersDivision of Critical Care Anesthesiology Vanderbilt University Medical Center

Jason Kennedy, MDAssistant Professor of Clinical AnesthesiologyDivision of Critical Care Anesthesiology Vanderbilt University Medical Center

Josh Billings, MDAssistant Professor of Clinical AnesthesiologyDivision of Critical Care Anesthesiology Vanderbilt University Medical Center

Warren Sandberg, MD, PhDProfessor and Chair

Department of AnesthesiologyVanderbilt University School of Medicine

Jeremy Bennett, MDAssistant Professor of Clinical AnesthesiologyDivision of Cardiovascular Anesthesiology Vanderbilt University School of Medicine

Mias Pretorius, MDAssociate Professor of Clinical AnesthesiologyAssistant Director, Thoracic AnesthesiologyDivision of Cardiovascular Anesthesiology Vanderbilt University School of Medicine

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Vanderbilt University School of Medicine

Adult Cardiothoracic Fellowship Program

Application Information

Timeline and Requirements (this document contains supplemental information regarding the application process and is not part of the actual application.)

This timeline is in accordance with the Adult Cardiothoracic Anesthesiology Program Directors Agreement. For more information, you can also visit the website of the Society of Cardiovascular Anesthesiologists website at http://www.scahq.org/

Applications for the Vanderbilt University Adult Cardiothoracic Anesthesia Fellowship must include the following documents:

1. Curriculum Vitae 2. Statement of Purpose 3. 3 Letters of Reference, one of which must be from your current Residency Program Director or

equivalent. 4. Completed Vanderbilt Application 5. Background Check Consent Form 6. A copy of your USMLE parts I,II and III scores 7. Official Dean’s Letter (Medical Student Performance Report/MSPR)8. Medical School Transcript 9. ECFMG certification (if applicable)

If you are not a U.S. Citizen, please include: 1. • Appropriate Visas

Please refer to the application for more details, or contact the Program Coordinator. Send your completed application and all of the required documents to: Program Coordinator

Adult Cardiothoracic Anesthesia Fellowship Program Vanderbilt University School of Medicine 1215 21st Avenue South, 5160 MCE NT, Campus Box 8274 Nashville, TN 37232-8274 If you have any questions or you’d like to have more information, please feel free to contact Ronan Walker, Program Coordinator at 615 322-4650 or by e-mail at [email protected] We look forward to hearing from you!

When to apply…

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We will accept applications for the 2015-2016 academic year from January 2, 2014 through March 3, 2014. Our program participates in the SF Match system for candidate selection. If you wish to apply for the Vanderbilt Adult Cardiothoracic Anesthesia Fellows' Program, visit the SF Match website at https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=24&typ=1&name=Adult%20Cardiothoracic%20Anesthesiology, click on the Register" button and follow the prompts. There will be a nominal fee charged by the SF Match organization for registering your application. Also be sure to read, complete, and send all of your application materials to Ronan Walker. The application is included on pages 12 through 20 of this brochure. If you have any questions, contact [email protected]
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Program Information

Annemarie Thompson, MD

Associate Professor of Anesthesiology and MedicineDepartments of Anesthesiology and Internal Medicine Program Director, Adult Cardiothoracic Anesthesia Fellowship Vanderbilt University Medical Center 1215 21st Avenue South, 5160 MCE NT Nashville, TN 37232-8274 615 322-4650 [email protected]

Vanderbilt Department of Anesthesiology

Division of Cardiothoracic Anesthesia

Keys to a successful application to the

Vanderbilt Adult Cardiothoracic Anesthesia Fellowship

Excellent letters of recommendation that are thoughtfully constructed and composed, and that demonstrate not only a high opinion of the applicant, but also outline a highly positive personal working experience with the applicant. An excellent academic record. Thoughtful and concise statement of purpose that briefly demonstrates a broad foundational fund of knowledge, and outlines your ambition and intentness. A thoroughly completed application. A well-organized CV.

Given that we receive dozens of qualified and potentially “successful” applications, the applicant who becomes a candidate will make an impression that is not easily described or outlined with words, and can only be described as the right combination of intensity, alacrity and honesty. Ultimately it’s up to the applicant to determine how, exactly, to set themselves apart.

Elizabeth StrockProgram Coordinator, Adult Cardiothoracic Anesthesia Fellowship Vanderbilt University Medical Center 1215 21st Avenue South, 5160 MCE NT Nashville, TN 37232-8274 615 322-4650 [email protected]

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VanderbiltAdult Cardiothoracic Anesthesiology

Fellowship ProgramApplication

Please print the following 9 pages, complete and mail your original application along with all required documents to the address indicated on

the application.

Letters of reference may be sent separately from your applicationto the same address.

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Vanderbilt University

Fellowship Criteria and Required Cardiothoracic Anesthesiology

Applicant: Please provide in the following categories to complete your on for Fellowship in Cardiothoracic Anesthesiology at Vanderbilt University. Use the completed column to indicate the inclusion of each component. The proceeding pages are required in the Vanderbilt University format.

Elizabeth StrockAAII/Program CoordinatorVUMC Department of Anesthesiology1215 21st Avenue S., Suite 5160 MCE NT

Nashville, TN 37232-8274

If you have questions or concerns:

Fax: 615 [email protected]

Annemarie Thompson, MDAssociate Professor Anesthesiology and Medicine, Departments of Anesthesiology and Internal MedicineProgram Director, Adult Cardiothoracic Anesthesiology Fellowship ProgramDivision of Cardiovascular AnesthesiologyVanderbilt University School of Medicine1215 21st Avenue S., Suite 5160 MCE NT

Nashville, TN 37232-8274

Once the above application components have been gathered and completed, please mail your application to:

Fellowship Eligibility CriteriaCheck

when completed:

Satisfactory completion of U.S. Residency Program in Anesthesiology

Please Provide the Following Documentation:• Curriculum Vitae• Statement of Purpose – (form attached)• 3 Letters of Reference (one of which must be from your Residency Program Director or equivalent)

• Medical School Official MSPE (Dean’s Letter)• Medical School Transcript• USMLE scores, parts I, II and III• Background Check – (consent form attached)• ECFMG – (if applicable)

If you are not a U.S. Citizen, please include:• Appropriate Visas – (and indicate the type of Visa)

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1 OF 9 APPLICATION PAGES

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Last Name: Academic year: 2015-2016 Additional info (optional):
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(Completion required prior to start of the academic year for which you are applying)
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This application can be filled electronically by typing in the fields provided, or you may print pages 12 - 20 and complete it by hand.
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Fill in completion date
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Vanderbilt University  

Statement of Purpose and Notes on Application  

 

Statement of Purpose (you may use a separate sheet of paper):                                 Please use this space to indicate any necessary notes on required application components: 

 

    

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A passport size photo, signed on the back, if not provided at the time of application will be required when coming for an interview.

5th, 6th, 7th, 8th, 9th

LAST FIRST MIDDLE

(STREET) (CITY) (STATE) (ZIP CODE)

(STREET) (CITY) (STATE) (ZIP CODE)

(TITLE) (DEPARTMENT) (INSTITUTION)

(YEAR)(DAY)(MO) (STATE/COUNTRY)(CITY)

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MC 3311 (4/94)---page 1 of 4

Vanderbilt University Medical Center And AFFILIATED INSTITUTIONS APPLICATION FOR TRAINING (Clinical Fellowship)

I hereby apply to the Vanderbilt University Medical Center and Affiliated Institutions for residency/clinical

fellow training at the PGY year level in the Department of Anesthesiology.

Preferred Effective Date of Appointment: _______________________________________________________

NAME:___________________________________________________________________________________ PRESENT ADDRESS:_________________________________________________________________ TELEPHONE NUMBER:____________________ SOCIAL SECURITY NO. ____________________

PERMANENT ADDRESS: ________________________________________________________________

Personal (permanent) E-Mail Address:__________________________________________________________ PRESENT STATUS:________________________________________________________________________ DATE OF BIRTH: _____________________________ PLACE OF BIRTH: ____________________________ CITIZENSHIP: _____________________________________________________________________________

IF NOT U.S. CITIZEN, TYPE OF VISA: _____________________________________________________

NAME AND ADDRESS OF SPOUSE OR NEAREST RELATIVE: _______________________________ ________________________________________________________________________________________________________

LIST ANY REASONS, IF ANY, THAT WOULD PREVENT YOU FROM PERFORMING THE ESSENTIAL FUNCTIONS OF A HOUSE OFFICER. IF ANY, PLEASE EXPLAIN _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

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MC 3311 (4/94)---page 2 of 4 EDUCATIONAL BACKGROUND: Please request the Dean of the Medical School you attended to send a

letter and a transcript of your grades. COLLEGES AND UNIVERSITIES ATTENDED (Include Dates and Degrees): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ MEDICAL SCHOOL (Include Dates): __________________________________________________________ ___________________________________________________________________ ACADEMIC HONORS (College and Medical School): _____________________________________________ ___________________________________________________________________ PROFESSIONAL EXPERIENCE: INTERNSHIP (Include Hospital and Location; whether Rotating, Mixed, or Straight; and Dates): ___________________________________________________________________ RESIDENCY (Include Hospital and Location, Specialty and Dates): _________________________________________________________________________________________________________________________________________________________________________________________________________ POSTGRADUATE TRAINING OTHER THAN ABOVE (Fellowship, Courses in Basic Science, Summer

Research, etc. Include Location, Type of Activity, and Dates): ________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________ MEMBERSHIP IN SCIENTIFIC AND PROFESSIONAL ORGANIZATIONS: _________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________

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MC 3311 (4/94)---page 3 of 4 HAVE YOU BEEN PARTY TO ANY MALPRACTICE LIABILITY CLAIMS, SUITS, AND/OR SETTLEMENTS? Yes ___ No ___ (If yes, please attach a summary) _______________________________________________________________

______________________________________________________________________________________________________________________________________ LICENSURE: Are you currently licensed to practice medicine? _______________________ If so, please indicate: STATE ___________________________ LICENSE NUMBER ___________________________________________________ Has your license ever been suspended, revoked, or voluntarily surrendered? Have you ever been disciplined, in any way, by a licensing board? If so, Please explain: ____________________________________________________________________________ CRIMINAL RECORD: Have you ever been convicted of a crime, other than a minor traffic violation: If so, please explain:

______________________________________________________________________________________________________________________________________ REFERENCES (Please submit names and addresses of three physicians who are acquainted with your academic and/or professional experience and your personal character): ________________________________________________________________

______________________________________________________________________________________________________________________________________ MILITARY EXPERIENCE: ACTIVE DUTY IN ARMED FORCES (Include Rank, Branch of Service, and Dates): ______________________________________

___________________________________________________________________ RESERVE OR NATIONAL GUARD STATUS: ____________________________________________________________________

___________________________________________________________________ ARE YOU OBLIGATED, THROUGH A HEALTH PROFESSIONS LOAN, FOR MILITARY OBLIGATION?

___________________________________________________________________ COMMENTS (Please indicate any special experience or qualifications not covered in this form): _____________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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MC 3311 (4/94)---page 4 of 4 FUTURE PLANS: (Describe your program for continued training) “In compliance with federal law, including the provisions of Title IX of the Education Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, Vanderbilt University does not discriminate on the basis of race sex, religion, national or ethnic origin, age, disability, or military service in its administration of educational policies, programs, or activities; its admissions policies; scholarship and loan programs; athletic or other University-administered programs; or employment. Inquires or complaints should be directed to the Opportunity Development Officer, Baker Building, Box 1809 Station B, Nashville, TN 37235. Telephone (615) 322-4705 (V/TDD); fax (615) 421-6871.” If I accept the appointment on the House Staff of Vanderbilt University Medical Center. I agree to serve the full term and to abide by the rules and regulations of the Medical center and Service to which I am attached. I certify that the information provided in this application is true and correct. SIGNATURE OF APPLICANT: _______________________________________________ DATE: ________________________ Appointment to House Staff is made by the Hospital on the recommendation of the Chief of Service and is for one year only.

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Disclosure Form Regarding Consumer Report for House Staff Appointments

(Vanderbilt and Visiting/Rotating From Other Institutions)

Please be advised that in connection with your application for a house staff appointment a consumer report and/or an investigative consumer report * will be obtained from a consumer-reporting agency for the purpose of evaluating you for assignment and/or employment as a Vanderbilt resident/clinical fellow or visiting resident/visiting clinical fellow. You have a right to request disclosure of the nature and scope of the report, which involves interviews with sources such as former employers, and a summary of consumer rights. The consumer report includes:

Criminal History Department of Motor Vehicle History (position specific) Certification and Licensing Education Credentials Employment Eligibility (Social Security Number Check) Employment Checks Reference Checks Credit Check (position specific) Sex Offender Status In addition, other areas may be investigated depending on the nature of the position

By signing the Vanderbilt consent form, I am authorizing Vanderbilt University to procure a consumer report and/or an investigative consumer report on you, to be used for assignment and/or employment purposes.

The Fair Credit Reporting Act gives you specific rights, for complete text of the FCRA, please reference their website at http://www.ftc.gov. * An investigative consumer report may include personal interviews to obtain information on a person's character, general reputation, personal characteristics, or mode of living.

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Consent for Reference and Background Checks for House Staff Appointment and/or Employment

I recognize that any offer of a House Staff position (Vanderbilt or Visiting) to me by Vanderbilt is conditional upon my successfully passing reference and background screenings. I understand that VANDERBILT and STERLING TESTING, INC. shall conduct reference and background checks thoroughly and within the confines of all applicable state and federal laws.

In consideration of Vanderbilt’s review of my application, I hereby release any individual, entity, governmental or other agency providing information pursuant to this Consent and Vanderbilt University from all claims or liabilities that arise from the inquiry into or disclosure of such information, including but not limited to any claims for defamation or invasion of privacy. This release is not intended to waive or release any duties, responsibilities, or liability arising out of the Fair Credit Reporting Act.

I hereby voluntarily consent to and authorize STERLING TESTING, INC., or its authorized representative bearing this release or copy thereof, in connection with my application with Vanderbilt University, to obtain a consumer report and/or an investigative consumer report for employment purposes including:

Criminal History Department of Motor Vehicle History (position specific) Certification and Licensing Educational Credentials Employment Eligibility (Social Security Number Check) Employment Checks Reference Checks Credit Check (position specific) Sex Offender Status Other: _______________________

I further authorize that a photocopy or facsimile of this authorization be considered as valid as the original. If it is your intent to authorize Vanderbilt to conduct a background check, please complete the Consent For House Staff Reference and Background Checks. According to the Fair Credit Reporting Act, I understand that I am entitled to know if assignment is denied because of information obtained from a consumer background reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.

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CONSENT FOR HOUSE STAFF REFERENCE AND BACKGROUND CHECKS

I have read the Consent for Reference and Background Checks. I understand that if I do not consent to the background checks within two weeks of receiving a conditional offer of assignment, the offer is withdrawn. I hereby authorize, without reservation, any person who may have information relevant to this investigation, including but not limited to any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by VANDERBILT and/or STERLING TESTING, INC., or their agents to furnish the information described on the front page of this consent form and consent to these pre-employment reference and background checks. ____________________________________ ______________________ Signature Date The following information will be used to conduct the reference and background checks. PLEASE PRINT

______________________________________________________ (Last, First MI) (Maiden) *Date of Birth: _____________________ ____________________ Month/Day/Year Social Security # ________________________ _____________ Driver’s License Number State of Issue Current Address __________________________________________________

Street/Apt ____________________________________________________________

City State Zip Code Telephone Number (____) ______________ Last Prior Address ____________________________________________________________ Street/Apt City State Zip Code If any additional information relative to change of name or use of an assumed name or nickname is necessary to enable a check on your background, please explain: ___________________________________________________ ___________________________________________________

*In order to verify my identity for purposes of the background investigation I am voluntarily releasing my date of birth for my own benefit and fully understand that age is not a consideration of assignment and/or employment.

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If you have questions or comments, we would love to hear from you...Contact Ronan Walker at 615.322.4650 or [email protected]