DGSOM at UCLA Affiliation Agreement Request Form

AFFILIATION AGREEMENT REQUEST FORM

Request forms should be submitted at least 90 days prior to the proposed effective date of the agreement. In rare instances, affiliation agreements may take 6+ months to process.
Todays Date

MonthDayYear
Date
DGSOM at UCLA Administrator/Requestor Information
Full Name*

First NameLast Name
Title*
E-mail*
example@example.com
Department*
Phone Number*

Area CodePhone Number
Academic Program*
Type of Agreement (check all that apply)*

Incoming (Non-UCLA Trainees coming to UCLA)Outgoing (UCLA Trainees going to another institution)Bilateral (Both incoming and outgoing)
For outgoing rotations only, please confirm prior to submitting this request that the affiliate does not have policy-based restrictions on care (i.e., restrictions on gender- affirming care, abortion, etc.).

I have confirmed that the affiliate DOES NOT have policy-based restrictions on careI have confirmed that the affiliate DOES have policy-based restrictions on care
Onboarding

Please keep in mind that many sites require a 60-day lead time for onboarding.
Approximate Start Date of Rotation (this will determine whether the execution of this agreement is urgent and top priority)*

MonthDayYear
Date
Approximate End Date of Rotation*

MonthDayYear
Date
Comments regarding the start/end date of the rotation
Program Director/Chair Name*

First NameLast Name
Program Director/Chair Email*
example@example.com
Program/Course Name*
Name of Trainee

First NameLast Name
Please indicate if the trainee is a resident or fellow

ResidentFellow
Please Describe the Educational Impact/Rationale of Pursuing an Affiliation agreement with the proposed Training Site. *
Facility/Affiliate Information
Legal Business Name (please confirm with Affiliate as I will use their legal name when sending the AA template)*
City/State of Affiliate
Affiliate Contact Name (This should be the administrator/contracts manager)*
Affiliate Contact Email Address*
example@example.com
Additional Comments or Information
Please upload any relevant documents here. This could include PLAs, expired agreements, email threads, etc.

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Cancelof
I understand that Morgan will copy the Program Coordinator on the email to the affiliate institution to keep them in the loop.*

Yes
I understand that Morgan will only make two attempts to contact the the affiliate if she does not receive a response. If the affiliate does not reply to the two emails, Morgan will ask the program coordinator/director to follow up with them.*

Yes
Should be Empty:

AFFILIATION AGREEMENT REQUEST FORM

DGSOM at UCLA Administrator/Requestor Information

Onboarding

Facility/Affiliate Information