For Health Professionals

Required Forms

Required forms for Intern Class of 2012

You will need to complete a number of forms in order to begin your residency at Children’s Hospital of Pittsburgh of UPMC in June. Below is a checklist of all the required forms, which are available on the Residents’ SharePoint Site. Please print out the forms, complete, and submit to the Residency Office, unless otherwise indicated.

Residency Office

Children’s Hospital of Pittsburgh of UPMC
Pediatric Residency Office
c/o Machele Maus
4401 Penn Avenue, AOB, Suite 5400
Pittsburgh, PA 15224

Checklist

Resident Contract
PA Training License
UPMC Employee Health Services Screening/Questionnaire
PA Child Abuse Clearance – Act 33
PA Criminal Background Check
FBI Clearance and Fingerprinting – Act 73
Miscellaneous Forms
- UPMC Graduate Medical Education Academic and Personal History Form
- Employee Information Form
- GME PSD Appointment Form
- Tri-Century Insurance Company Form
- Children’s Pharmacy Medication Access ID Application
- Physician’s Temporary DEA Application
- Perkin Elmer
- Children’s Hospital of Pittsburgh Confidentiality Agreement
- UPMC 3rd Party Computer Access Agreement
- American Board of Pediatrics Consent Form
- PA Statewide Immunization Information System Agreement
Documentation (Passport, Driver's License, Permanent Resident's Card, Social Security Card)
BLS Certification
White Coat and Scrub Order Form
UPMC Modules