Remediation Consult Request
Your Information
Name
*
First Name
Last Name
Degree
Position
*
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Institution
*
3 or 4 year training program?
*
3 Year Program
4 Year Program
How long has your program been accredited?
Resident/Trainee Information
PGY Level of Resident
*
PGY 1
PGY 2
PGY 3
PGY 4
Degree of Trainee
*
MD
DO
Did you match this resident in the main NRMP match?
*
Yes
No
Was this resident matched in SOAP?
Yes
No
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?
*
Yes
No
If yes, does your contract include (check all that apply)
Timeline/time frame for the current phase of remediation
Description of the deficiencies
Objectives/interventions aimed to improve performance
Description of data/information that will be used to track progress
Consequences/next steps in the event of unsuccessful remediation
Advisement to the trainee about the possibility of future reporting to outside partieswith vested interest
Resident’s signature
Please identify the competencies being addressed (check all that apply):
*
Professionalism
Medical Knowledge
Patient Care
Practice Based Learning & Improvement
Interpersonal and Communication Skills
Systems 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.
*
Yes
No
Submit
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