Consultant Confidentiality Agreement

Remediation Consult Request

Your Information
Name*

First NameLast NameDegree
Position*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Institution*
3 or 4 year training program?*
How long has your program been accredited?
Resident/Trainee Information
PGY Level of Resident*
Degree of Trainee*
Did you match this resident in the main NRMP match?*

YesNo
Was this resident matched in SOAP?

YesNo
Other match type?
How long have you been actively managing this resident’s deficiencies?*
(includes any intervention such as performance improvement plans, formal remediation,etc)
What is the current remediation status of your resident? *
Coaching, informal remediation (action plan,PIP, etc), Formal remediation, Probation
Have you implemented a formal remediation contract at this time?*

YesNo
If yes, does your contract include (check all that apply)

Timeline/time frame for the current phase of remediationDescription of the deficienciesObjectives/interventions aimed to improve performanceDescription of data/information that will be used to track progressConsequences/next steps in the event of unsuccessful remediationAdvisement to the trainee about the possibility of future reporting to outside partieswith vested interestResident’s signature
Please identify the competencies being addressed (check all that apply):*

ProfessionalismMedical KnowledgePatient CarePractice Based Learning & ImprovementInterpersonal and Communication SkillsSystems Based Practice
Please provide a narrative description of your resident’s deficiencies, prior or on-going interventions by your program, and specific questions you have*
It is important for the CORD Remediation Committee to track outcomes so we can determine the efficacy of our recommendations to inform future consultations. Are you willing to be contacted by a CORD remediation committee member in 6-12 months to discuss the status of your remediation process? All information received and handled by CORD remains confidential and de-identified.*

YesNo
Should be Empty:

Remediation Consult Request

Resident/Trainee Information