Current Appointment Change Form

This form is for any of the following modifications to a resident or fellow's current appointment: chief designation, overnight call, training extension, and training reduction to also align with the Workday appointment. Note: The program contact will still need to communicate approved changes with their department HR to input these changes in Workday. For any questions, please contact Shinetra Pryor at snpryor@uw.edu. Thanks!

Program Contact First & Last Name

Program Contact Email

Department

Program

Resident/Fellow First & Last Name

Resident/Fellow R-Level

Resident/Fellow Title

Please select from the list below which appointment change type(s) is being requested:

Chief Designation

Overnight Call

Training Extension

Training Reduction

Chief Designation

Start Date

(mm/dd/yyyy)

End Date

(mm/dd/yyyy)

Additional Comments?

Overnight Call

Current Appointment End Date

(mm/dd/yyyy)

Is resident/fellow clinical coverage required?

Yes

Please explain the request for overnight call:

Training Extension

Current Appointment End Date

(mm/dd/yyyy)

Requested Extension End Date

(mm/dd/yyyy)

Reason for extension?

Is training extension due to a leave of absence?

Yes

If the extension is a result of taking a leave of absence, please ensure the impacts of the extension have been discussed and review program responsibilities. Additional Leave resources can be found here.

Is additional FTE being requested?

Yes

FTE needed for extension (list all applicable hospitals)

Please list amount of additional FTE needed per hospital (Guideline: One month = 0.08 FTE)

Will the program need an ACGME complement increase?

Yes

A temporary complement increase may be needed if the number of trainees exceeds the approved ACGME complement. For multi-year programs, a temporary increase of up to 90 days does not require Review Committee approval and should not be submitted in ADS. Requests for more than 90 days must be submitted through ADS. Single-year programs may need to submit requests even for periods under 90 days.

Additional Comments?

Training Reduction

Current Appointment End Date

(mm/dd/yyyy)

Requested Reduction End Date

(mm/dd/yyyy)

Reason for Training Reduction

Are there boards for this program?

Yes

Does reduction meet board eligibility or program Effects of Leave policy?

Yes

Please explain:

Will trainee still be on track for program graduation?

Yes

Additional Comments?

If you are human, leave this field blank.

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Chief Designation

Overnight Call

Training Extension

Training Reduction

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