ACLS POLICY FOR RESIDENTS

2023-2024 RESIDENT POLICIES AND PROCEDURES

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

Contents Page

I ACLS Policy 3

II Accommodations for Residents with Disability Policy 5

III Campus Health Services Office

a. Services Provided 6

b. Immunization Requirements and Policy 7

c. Exposure to Bloodborne Pathogens 8

d. Mental Health Services 9

IV Compliance with Teaching Physician Regulations Policy 10

V Delinquent Medical Records 11

VI Disaster Policy 12-13

VII Drug Free School Notice 14

VIII Due Process

a. Academic Probation 15

b. Grievance Procedure 16-17

IX Resident Work Hours Policy and Procedures 18-22

X Evaluation, Promotion, and Termination Policy 23

XI Email Accounts 24

XII Fringe Benefits 25-27

XIII HIPPA 28-29

XIV House Staff Council 30

XV Impaired Residents/Substance Abuse Policy 31

XVI Foreign Nationals and International Medical Graduates 32-33

XVII Leave Time

a. Leave of Absence Policy 34-39

b. Resident Vacation 40-41

XVIII Malpractice Coverage 42

XIX Medical Licensure Policy 43-44

XX Moonlighting Policy 45-46

XXI MedHub 47

XXII Away Rotations 48-50

XXIII Pay Schedule and Paychecks 51

XXIV Pre-Employment Background Check Policy 52-53

XXV Program Closure Policy and Procedure 54-55

XXVI Restrictive Covenants Policy 56

XXVII Sexual Harassment Policy 57

XXVIII Student Mistreatment Policy 58

XXIX Resident Selection Policy and Procedure 59-61

XXX Supervision Policy 62-63

XXXI Training Sites 64-72

XXXII Transition of Care and Handoff Policy 73-75

XXXIII Vendor Policy 76-78

XXXIV Inclement Weather Policy 79

XXXV Worker’s Compensation 80-81

XXXVI Board Eligibility 82

Published by:

Office of Graduate Medical Education

University of Louisville School of Medicine

323 E. Chestnut St.

Louisville, KY 40202 (502) 852-3134

Resident Policies and Procedures

Section I.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

ADVANCED CARDIAC LIFE SUPPORT (ACLS) FOR RESIDENTS

POLICY & PROCEDURE

Background (Intent)

All incoming residents and fellows are required to be ACLS certified by an American Heart Association (AHA) approved

training center except as noted below. This is the agreement we have with our partner hospitals.

Definitions (As used in this Document)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME Office,

including interns, residents, and fellows. Residents in University of Louisville School of Medicine training

programs are classified as students (see item #7 in the Resident Agreement).

Policy

Initial Certification

1. Trainees in University of Louisville postgraduate training programs must have American Heart Association (AHA)

Advanced Cardiac Life Support (ACLS)* certification prior to beginning training in UofL GME sponsored

programs, except as noted:

a. Pediatric residents and fellows must obtain Pediatric Advanced Life Support (PALS) instead of ACLS.

Red Cross PALS certification is acceptable

b. Obstetrics & Gynecology residents, Pediatric residents, and Neonatology fellows must obtain certification

in Neonatal Resuscitation Program (NRP).

c. Medicine-Pediatrics residents must obtain ACLS, PALS, and NRP.

d. Glasgow Family Medicine residents may obtain Red Cross ACLS certification in lieu of AHA

e. Exemptions: Forensic Pathology, Child & Adolescent Psychiatry, and Developmental-Behavioral

Pediatrics fellows are exempt from this requirement. Any trainees in programs that do not require a

medical or dental degree are also exempt.

*Students in ACLS courses are expected to be proficient in BLS skills. Training Centers may require students to

have a current BLS for Healthcare Providers card. It is recommended that both BLS and ACLS be obtained by new

residents prior to their arrival in Louisville if they have not been certified at their schools.

2. The expiration date for certifications must be no later than the program start date.

3. A 30-day grace period may be permitted but must be requested in advance from the Graduate Medical Education

Office.

Recertification and maintenance

1. When re-certification is required as part of the residency training program, the department must provide the

training without cost to the resident.

2. Recertification and maintenance of an active certificate in Advanced Cardiac Life Support (ACLS) is required for

all residents in Anesthesiology, Emergency Medicine, Family Medicine, Radiology, categorical and preliminary

Internal Medicine, Gastroenterology, Pulmonary and Critical Care Medicine, Sleep Medicine, and Cardiology.

3. Recertification and maintenance of an active certificate in Pediatric Advanced Life Support (PALS) is required for

all residents in pediatrics and in all pediatric fellowships with the exception of Child & Adolescent Psychiatry and

Developmental-Behavioral Pediatrics.

4. Neonatology fellows must maintain active certification in Neonatal Resuscitation Program (NRP).

5. Medicine-Pediatrics residents must remain actively certified in both ACLS and PALS.

6. Other departments may require recertification at their option.

Procedure

1. Documentation and recordkeeping will be the responsibility of each program. Programs must enter and maintain

current data on certifications for all trainees via MedHub.

Approval

Approved: 05/16/01; Amended: 05/23/01; Effective: 07/01/01; Revision approved: May 18, 2016. Revision approved: April

1, 2019. Revision approved by GMEC March 26, 2021. GMEC April 21, 2021. Revised April 2023 regarding limited

acceptance of Red Cross certification.

Resident Policies and Procedures

Section II.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

ACCOMODATIONS FOR RESIDENTS WITH DISABILITIES

Policy & Procedure

Definitions (As used in this Document)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME Office,

including interns, residents, and fellows. Residents in University of Louisville School of Medicine training

programs are classified as students (see item #7 in the Resident Agreement).

Policy

1. It is the policy of the University of Louisville School of Medicine to provide reasonable accommodations as

necessary for qualified individuals with disabilities who are accepted into our post graduate training programs. We

will adhere to all applicable federal and state laws, including the Americans with Disabilities Act , regulations and

guidelines with respect to providing reasonable accommodations as required in accordance with the policies and

procedures of the University of Louisville.

2. For the purposes of ADA, the University Disability Resource Center considers residents as employees (even

though the Redbook defines them as students).

Procedure

1. Residents must request accommodations in writing to the Program Director. The resident will be required to

provide medical verification of a medical condition that he or she believes is a disability. The resident is

responsible for the costs of obtaining verification. More information is on the Employee Relations website at

https://louisville.edu/hr/employeerelations.

2. The Program Director must notify the Designated Institutional Official (Graduate Medical Education Office) of the

request.

3. The resident must complete an ADA accommodation request form https://louisville.edu/hr/forms/ada-request.

Section 1 is completed by the resident and Section II by the resident’s healthcare provider. The complete form

must be sent to emrelate@louisville.edu

to start the ADA process

4. The Employee Relations Office will work with the resident and the program in determining if a resident has a

disability and what accommodations may be reasonable and necessary for the School of Medicine to provide.

Residents will still be required to meet all program educational requirements with or without accommodations as

they must be able to demonstrate proficiency in all of the ACGME defined competencies, and programs must

certify that residents have determined sufficient competence to enter practice without direct supervision upon

completion of training. This includes the ability to perform the required technical and procedural skills of the

specialty. Patient safety must be assured as a top priority in these determinations.

References & Related Policies

ACGME Institutional Requirements, Effective July 1, 2018, IV.H.4: The Sponsoring Institution must have a policy, not

necessarily GME-specific, regarding accommodations for disabilities consistent with all applicable laws and regulations.

(Core)

Approval

12/08/08

Approved by GMEC: April 1, 2019, Revised 11/30/2023

Resident Policies and Procedures

Section III.a.

Campus Health Services Office

(502) 852-6446 (Answered 24 hours/day)

Phillip F. Bressoud, MD, FACP

Executive Director

The Campus Health Services, located in the UofL L Healthcare Outpatient Center (HCOC) on the corner of Preston and

Chestnut Streets, provides immunizations, tuberculosis screenings, drug screening as well as occupational and routine

medical services for all HSC Health Professional students, residents and fellows. The CHS also serves as an on-site

treatment facility for workers compensation related injuries and exposures including needle sticks. The office is staffed by

board certified faculty physicians and nurse practitioners. All providers have extensive primary care and occupational

exposure experience. On-site laboratory and X-ray facilities are located adjacent to the office. The office is open daily from

8:30 to 4:30. Please call ahead to arrange an appointment if possible, but walk-ins will be accommodated.

Exposures involving HIV, Hepatitis B, Hepatitis C or other agents can be referred 24 hours a day to the provider on call.

After a post-exposure evaluation and determination of risk, the provider will determine if post-exposure prophylaxis (PEP)

is indicated. In the case of HIV positive exposures, access to antiviral drugs should be started within one hour of the

exposure. Only the on-call provider for the CHS can release the antiviral drugs from the University of Louisville in-

patient pharmacy to U of L employees, residents, and students. Please do not ask other house staff or attending

physicians to write for HIV post-exposure prophylactic drugs. Follow up testing and reporting of the exposure to

Workers Compensation can usually be completed the next working day.

Although you may choose any approved facility for workers compensation care, the CHS is prepared to minimize the time it

takes for you to be seen and return you to your clinical duties as soon as possible. Failure to use an approved facility can

result in denial of payment on your claim to Workers Compensation for treatment. The CHS works with the U of L Risk

Management Office to assist you in completing the necessary paperwork to process your claim. Failure to report an

injury or exposure can result in non-payment of any future claims. For example, if you become HIV positive after an

unreported exposure, Workers Compensation may not pay any claims for HIV or HIV related complications.

The CHS also serves as the repository of your immunization records and exposure data while you are in your residency. If

you attended medical school at U of L, your student data will be carried forward when you begin your U of L residency. If

requested, the CHS will provide you with a free copy of your immunization and PPD documentation when you leave the

University.

Resident Policies and Procedures

Section III.b.

Immunization Program

Campus Health Services Office

Health Sciences Center

University of Louisville

Louisville, KY 40292

POLICY ON IMMUNIZATION AND SKIN TEST REQUIREMENTS FOR RESIDENTS

UNIVERSITY OF LOUISVILLE

SCHOOL OF MEDICINE

These requirements have been established by the School of Medicine in recognition of our responsibility to provide for your

safety, and for the safety of patients whom you will encounter in the course of your training. In addition, they reflect the

standards established by the CDC and by the hospitals in which you will be working. It is the expectation of the

administration of the School of Medicine that you will accept the value of these conditions, and that you will accept the

responsibility for providing full documentation of your status as stipulated under each heading. You may not begin your

training unless the basic requirements are met, and your continuation as a resident will depend upon your remaining

in compliance. Residents found to be non-compliant for more than 30 days with this policy will be suspended from all

clinical duties and may be subject to disciplinary action including termination. Each resident is responsible for supplying

the required information and documentation to Campus Health Services. Immunization, TB skin tests and lab work are

provided at no cost to incoming and current residents through the HSC Health Services Office located in the HCOC suite

110.

Required Immunizations and Testing:

1. TDAP: 1 dose of Tdap (Tetanus, Diphtheria and Acellular Pertussis) vaccine within last 10 year

2. MMR: Documentation of serologic immunity OR

2 MMR vaccines (2 doses each of measles and mumps as well as 1 dose of Rubella

(if administered separately)

3. HEPATITIS B: 3 Doses Vaccine followed by a Hepatitis B Surface Antibody titer reported with a

quantitative value

4. VARICELLA 2 doses vaccine or positive antibody titer. Indeterminate titers require one dose vaccine.

5. COVID-19 2 doses of vaccine required AND recommend booster dose of vaccine

6. INFLUENZA 1 dose of vaccine each fall

7. BASELINE AND ANNUAL TB TESTING IS REQUIRED:

• No previous TST or your testing has elapsed >14 months- Complete two TSTs, at least one

week apart.

• No prior history of positive TST

• Proof of two annually consecutive TSTs: one within 90 days of your start date, OR

• -Interferon Gamma Release Assay (IGRA) (Quantiferon TB Gold or T-spot) within 90 days of

your start date.

• Prior history of (+) TST or IGRA, or active TB

o Provide documentation of positive test results, medication treatment, and latest Chest x-

ray report.

o -If you received the BCG vaccine and your first or second TST were “positive” you will

need to obtain an IGRA blood test.

o Complete TB Questionnaire (TBQ) upon starting and on an annual basis.

8. N95 MASK FIT TESTING

• Required annual to comply with local hospital OSHA requirements

Resident Policies and Procedures

Section III.c.

PROCEDURE FOR EXPOSURES TO BLOODBORNE PATHOGENS

UNIVERSITY OF LOUISVILLE

SCHOOL OF MEDICINE

If you experience a needle stick or other occupational blood exposure please do the following:

1. Obtain consent from the patient involved for HIV testing if necessary and contact nursing supervisor at facility

where the incident occurred.

2. Complete incident report at facility where injury occurred.

3. Call 852-6446 to discuss your exposure with the physician on call. HIV post exposure prophylaxis should be

started within one hour of the exposure, if possible.

4. During working hours, you may go to the Campus Health Services Office on the first floor of the Outpatient Care

Center at 401 East Chestnut St. We strive to keep your visit as short as possible and have all of the appropriate

worker’s compensation forms available if necessary.

5. You will be counseled at your visit and appropriate long term follow-up testing determined. It is your responsibility

to complete any follow-up testing.

6. Failure to complete a Worker’s Compensation Form may result in non-payment of claims and make the resident

responsible for any charges

Revised: 07/03; 07/04, 7/08; 2/14,3/14

Resident Policies and Procedures

Section III.d.

MENTAL HEALTH SERVICES FOR RESIDENTS

UNIVERSITY OF LOUISVILLE

SCHOOL OF MEDICINE

MENTAL HEALTH SERVICES

Confidential counseling or psychiatric consultation is provided at no charge to the resident through a contractual

arrangement between the Dean’s office and the Campus Health Services Office. Residents desiring or in need of personal

counseling, psychiatric consultation and/or treatment should contact one of the numbers below:

HSC Counseling Services Campus Health Services/Psychiatry Services

Shivaun Nafsu, M.A.,MSW,LCSW Brian Casey, MD

Wilethia Durham, MS,LPCC-S Courtney Eaves, MD

UofL Outpatient Center U of L Outpatient Center

401 East Chestnut St, Suite 110 401 East Chestnut St, Suite 110

502-852-6446 502-852-6446

Revised 07/03; 04/20/05; 5/07/2007, 4/1/10, 2/19/14, 3/14/19, 2/6/20, 3/15/22

Resident Policies and Procedures

Section IV.

POLICY ON COMPLIANCE WITH TEACHING PHYSICIAN REGULATIONS

SCHOOL OF MEDICINE

UNIVERSITY OF LOUISVILLE

1. The Centers for Medicare and Medicaid Services’ (CMS) Medicare’s Final Rule for Teaching Physicians was

effective July 1, 1996 and revised on November 22, 2002. This rule outlines the documentation criteria for

physicians in teaching institutions.

2. Representatives of CMS indicate that audit and enforcement activities will continue relative to teaching institutions.

Failure to comply with the applicable rules can lead to serious civil penalties, criminal prosecution and exclusion of

a provider. It is our sincere desire that neither any U of L physician nor the University suffer the possible serious

consequences that could result from either not understanding or not following the rules.

3. Accordingly, the U of L School of Medicine is seeking to be pro-active in implementing these new rules by

providing faculty, residents and staff educational sessions and reference materials. It is mandatory that all residents

attend or complete an online session since compliance involves efforts by you and the School of Medicine.

Training is provided by the UofL Physicians Compliance and Audit Services.

4. Residents are required to attend and complete an educational session on the CMS Teaching Physician Regulations

within 30 days of hire. Failure to comply with this requirement within 30 days of hire will result in the resident

being placed on academic probation for fifteen days by the Dean of the School of Medicine. If after fifteen days of

academic probation the resident still has not completed the required training, the resident will be suspended from

his/her training program. Suspension will include cessation of clinical training duties and removal from payroll

status. If the training has not been completed after 15 days of suspension, the resident’s contract will be

terminated.

5. Compliance training will be an annual requirement for all residents. Failure to comply with this annual

requirement within the 60 days of its offering will result in the sanctions as noted in #4 and possible training

charges for non-completion within the stipulated 60-day period.

Contact:

Jaimie Hanifern, CHC

System Director, Compliance and Privacy

UofL Health

Jaimie.hanifern@uoflhealth.org

502-588-2302

Revised: 3/10/00; 07/03; 07/04;07/14

Resident Policies and Procedures

Section V.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

POLICY ON PROBATION, SUSPENSION, AND TERMINATION

FOR DELINQUENT MEDICAL RECORDS AT AFFILIATED HOSPITALS

1. A resident who is identified as having incomplete medical records (any record greater than 7 days past hospital

discharge) by any of the Record Departments of the affiliated hospitals will be notified by the respective Medical Records

department and given 7 days to complete the records in question. At that time, the resident will also be notified that if

he/she does not complete the medical records within 7 days that he/she will be recommended to be placed on probation.

2. If at the end of the 7-day period the records have not been completed, the Director of Medical Records will notify

the Associate Dean for Graduate Medical Education, who will recommend to the Dean that the resident be placed on

probation. The resident will be notified in writing by the Dean of the probationary status.

3. Once placed on probation, the resident will be given 7 additional days to complete all additional records at all

affiliated hospitals and notified that if records are not completed at the end of 7 days, the resident will then be recommended

to be suspended.

4. The Medical Records Department of the appropriate hospitals will notify the Associate Dean for Graduate Medical

Education if the medical records in question have not been completed at the end of the 7-day probationary period. The

Associate Dean in turn will recommend to the Dean that the individual be suspended. The Dean will notify the individual

resident of the suspension in writing. The Dean will notify the resident's Program Director and the Chairman of the

Department.

5. Suspension will include the following conditions:

A. Resident will be relieved of all clinical duties.

B. The resident will receive no credit for training while in suspended status.

C. The suspension will continue until all delinquent medical records are completed.

6. If at the end of 30 days suspension period the resident has failed to comply, a recommendation will be made to the

Dean from the Associate Dean that the resident be terminated/dismissed from the training program.

7. All available medical records should be completed prior to a resident departing for a vacation, leave of absence, or

any out-of-town or out-of-state rotation since the above probation, suspension, and dismissal process will apply in these

cases.

8. Prior to a resident departing from a program and receiving any credit or certification for the period of training, all

medical records must be completed at all affiliated hospitals.

Revised: 4/2000; 2/10/04; 02/05/08; 4/20/2011;2/2020

Resident Policies and Procedures

Section VI.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

DISASTER & EXTRAORDINARY CIRCUMSTANCES

POLICY & PROCEDURE

BACKGROUND (INTENT)

The Sponsoring Institution must maintain a policy consistent with ACGME Policies and Procedures that addresses

administrative support for GME programs and residents in the event of disaster or interruption in patient care.

DEFINITIONS (AS USED IN THIS DOCUMENT)

Definition of Disaster: An event or set of events causing significant alteration to the residency experience at one or more

residency programs. Hurricane Katrina is an example of a disaster.

Extraordinary Circumstances: event that significantly alters the ability of a sponsor and its programs to support resident

education. Examples of extraordinary circumstances include abrupt hospital closures, natural disasters, or a

catastrophic loss of funding.

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME Office,

including interns, residents, and fellows. Residents in University of Louisville School of Medicine training

programs are classified as students (see item #7 in the Resident Agreement).

POLICY

Extraordinary Circumstances at the University of Louisville

1. The University of Louisville Graduate Medication Education Office and all university programs will abide by the

Accreditation Council for Graduate Medical Education’s (ACGME) Policy to Address Extraordinary

Circumstances as described in the ACGME Policies and Procedures effective June 10, 2017.

2. In the event of a disaster or interruption in patient care, within 10 days after the declaration of a disaster (see

above), the designated institutional official of each sponsoring institution with one or more disaster-affected

programs (or another institutionally designated person if the institution determines that the designated institutional

official is unavailable) will contact the ACGME to discuss due dates that the ACGME will establish for the

programs

3. The DIO working with the GMEC and other sponsoring institution leadership, will oversee development of

program specific plans for ensuring quality educational experience for residents and quality patient care for the

institution.

I. Program Plans must:

a. revise the educational program to comply with the applicable Common, specialty specific Institutional,

and Program Requirements within 30 days of the invocation of the policy: and,

b. arrange temporary transfers to other programs or institutions until such time as the program(s) can provide

an adequate educational experience for each of its residents and/or fellows; or,

c. assist the residents and/or fellows in permanent transfers to other ACGME -accredited programs in which

they can continue their education.

4. Approval of program plans will made by the DIO and the GMEC.

5. The DIO and the GME Office will coordinate and implement approved plans with the program and submit program

reconfigurations to the ACGME.

6. Resident contracts will continue to be in effect, and residents will continue to receive salary, benefits, and

professional liability coverage while under contract.

Extraordinary Circumstances at other Institutions

7. When the GME Office or a program is aware of extraordinary circumstances declared at another institution, the

Program Director should contact the DIO regarding the institution’s availability to accept transfers.

Institutions offering to accept temporary or permanent transfers from programs affected by a disaster must

complete a form found on the ACGME website. Upon request, the ACGME will give information from the form to

affected programs and residents. Subject to authorization by an offering institution, the ACGME will post

information from the form on its website. If needed, programs will follow all internal policies and procedures,

including but not limited to Selection and Increases in Complement.

Program Requirements

8. Programs will be responsible for maintaining current academic and personnel records of all residents in the

MedHub Residency Management System so that resident records will be available if office records are destroyed in

the disaster.

9. In the event of a declared extraordinary circumstance, programs are responsible for submitting a program plan to

the GME Office, per policy item 3.

PROCEDURE

1. When the ACGME deems that the University of Louisville’s ability to support resident education has been

significantly altered, the DIO will contact all affected programs requesting submission of alternate plans for

ensuring an adequate educational experience within 30 days of the invocation of the policy (per ACGME Policy

and Procedures).

2. The DIO will convene an emergency meeting of the GMEC to consider and approve submitted proposals.

3. The GME Office staff will assist programs to effect the necessary changes in order to comply with approved plans

for alternative educational experiences, including but not limited to arranging for temporary or permanent transfers,

temporary or permanent increases or decreases in complement, or ACGME site visits as needed.

4. Depending on the circumstances, specific information regarding any changes or delays in resident payroll will be

communicated from the UofL Payroll department and/or from the GME office.

REFERENCES & RELATED POLICIES

ACGME Institutional Requirements, Effective July 1, 2018 (IV.M.) Disasters: The Sponsoring Institution must maintain a

policy consistent with ACGME Policies and Procedures that addresses administrative support for each of its ACGME-

accredited programs and residents/fellows in the event of a disaster or interruption in patient care. (Core)

ACGME Policies & Procedures, Effective June 10, 2017, Subject 21.00

APPROVAL

Approved by GMEC: 08/20/08; 12/17/20108

Revision approved by GMEC: April 1, 2019

Revised February 5, 2024 to add language on resident pay and benefits

Resident Policies and Procedures

Section VII.

DRUG FREE SCHOOLS NOTICE

The University of Louisville is committed to protecting the safety, health and well-being of all students, faculty and staff

and other individuals in our workplace. We recognize that alcohol abuse and drug use pose a significant threat to our goals.

We have established a drug-free workplace program that balances our respect for individuals with the need to maintain an

alcohol and drug-free environment. As a recipient of federal grants and contracts, the university gives this notice to students,

faculty and staff that it is in compliance with the Drug-Free Workplace Act of 1988 (Pub. L.100-690, Title V Subtitle D)

and the Drug-Free Schools and Communities Act Amendment of 1989. Students, faculty and staff are herein notified of the

standards of conduct that will be applicable while on university property, business, and/or at university sponsored activities.

This policy is incorporated and is a part of the official University of Louisville Policies and Procedures.

You may view the University of Louisville Policy Statement as a Drug-Free Institution on the Human Resources web site:

http://louisville.edu/hr/policies/the-university-of-louisville-policy-statement-as-a-drug-free-institution

Physicians who require assistance may call the Kentucky Physician Health Foundation at 502-425-7761 or

https://kyrecovery.org/

Revised: 3/10/00, 3/1/04, 4/1/10, 4/27/11, 11/2021

Resident Policies and Procedures

Section VIII.a.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

ACADEMIC PROBATION AND DUE PROCESS POLICY FOR RESIDENTS

The Student Academic Grievance Procedure provides residents a fair means of dealing with actions or decisions which the

resident may feel to be unfair or unjust. The School of Medicine Student Academic Grievance Committee includes resident

representatives.

Residents in University of Louisville School of Medicine residency programs are classified as students (see item #7 in the

Resident Agreement) and as such are covered by the Student Academic Grievance Policy and Procedures outlined in The

Redbook, Chapter 6, Articles 6.6 through 6.8.14 (The Redbook is available on line at www.louisville.edu/provost). Article

6.6.3 grants each academic unit the responsibility and authority to make decisions in accordance with standards determined

by the unit. Academic units are also responsible for seeing that the standards determined are in agreement with their

respective RRC/ACGME and Board certification requirements.

The procedure to be followed when academic probation is recommended by a unit is:

1. Program Director (or Residency Evaluation Committee) makes recommendation to the Department Chair.

2. Department Chair makes written recommendation to the Dean (through the Vice Dean for Graduate Medical

Education). The written recommendation must include the reasons for the recommendation, the length of the

recommended probation and the expected resolutions to the problems.

3. The Dean reviews the recommendation and informs the resident of the probation action.

4. At the end of the probationary period, the Department Chair informs the Dean in writing (through the Associate

Dean for Graduate Medical Education) of the resident's progress, advising the Dean if the problem is resolved, if an

additional period of probation is necessary or if dismissal is recommended. The Dean takes the appropriate action

and informs the resident and the Department Chair and Program Director.

Revised: 5/26/2000

Revised 02/05/2008

Resident Policies and Procedures

Section VIII.b.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

RESIDENT GRIEVANCE DUE PROCESS PROCEDURE

Background (Intent)

Residency and fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME)

must function under the ultimate authority and oversight of one Sponsoring Institution. The ACGME has charged

sponsoring institutions, in this case the University of Louisville School of Medicine, with ensuring that formal written

policies governing resident clinical and educational environment be established at both the institutional and program level.

The Graduate Medical Education (GME) Office of the University of Louisville, School of Medicine ensures that the

individual training program’s policy, and practice, are in compliance with both the RRC and ACGME or other Accreditation

requirements.

Definitions (As used in this Document)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME Office,

including interns, residents, and fellows. Residents in University of Louisville School of Medicine training

programs are classified as students (see item #7 in the Resident Agreement).

Procedure

Preliminary Procedures

To pursue a grievance concerning academic matters within the academic unit, the following steps of the grievance procedure

may be observed:

1. The resident should first discuss the matter with the person involved and attempt to resolve the grievance through

informal discussion.

2. If there is no resolution, the resident should discuss the matter with that person's supervisor or the person to whom

such person reports, who should attempt to mediate a resolution.

3. If the resident still has not been able to obtain a resolution, he or she may request the Student Grievance Officer

(S.G.O.) (852-6102) to attempt informal mediation of the problem.

Grievance Procedures

4. If the matter has not been satisfactorily resolved through the informal process, the resident may submit a written

statement of the grievance to the School of Medicine Grievance Committee through the Office of the Dean.

The statement shall contain:

a. A brief narrative of the condition giving rise to the grievance;

b. A designation of the parties involved; and

c. A statement of the remedy requested.

5. The Chair of the Grievance Committee will call a meeting of the Grievance Committee to hear testimony from

grievant and the opposing party(ies). The Grievance Committee will be composed of faculty members and at

least one resident member. Faculty members or resident members who are from the grievant’s training

program must recuse themselves from the process. The action of the Grievance Committee is an academic

function, not a legal hearing. The grievant may have legal counsel in attendance, if desired, but the legal

counsel may not speak during the Grievance Committee meeting.

6. The Grievance Committee will deliberate on the information available to them and make a recommendation to the

Dean.

7. The Dean will make a decision based on the recommendation and inform the grievant and opposing party(ies) of

that decision. The Dean’s decision is final.

Approval 2/15/07; Revision approved by GMEC: April 1, 2019

Resident Policies and Procedures

Section IX.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

RESIDENT WORK HOURS POLICY & PROCEDURE

BACKGROUND (INTENT)

The Accreditation Council on Graduate Medical Education (ACGME) has charged sponsoring institutions, in this case the

University of Louisville School of Medicine, with ensuring that formal written policies governing resident clinical and

educational work hours be established at both the institutional and program level. Programs, in partnership with their

Sponsoring Institutions, must design an effective program structure that is configured to provide residents with educational

and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities.

The Graduate Medical Education Committee is responsible for and has established procedures for reviewing requests for

exceptions to the weekly work hours limits of up to 10 percent or a maximum of 88 hours. Requests must be justified on

educational grounds and must be approved by the GMEC before consideration by the appropriate Residency Review

Committee. Requests for an exception must follow the clinical and educational work hour exception policy from the

ACGME Manual of Policies and Procedures and the GMEC Procedure for Endorsing Requests for Resident Work Hours

Exceptions.

Any questions or concerns regarding this policy or work hour entry in Med-Hub should be directed to the GME Office via

the REWE Coordinator at (502) 852-5271. The GME Office can be reached anonymously or confidentially through the

Resident Ombuds line at (502) 852-0387 or through the DIO Anonymous Message to DIO/GME Director in Med-Hub [See

Messaging]. For additional resources for addressing work hour issues residents can contact a House Staff Council (HSC)

Representative by visiting the website: http://louisville.edu/medicine/org/housestaff

DEFINITIONS (AS USED IN THIS POLICY)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME Office,

including interns, residents, and fellows. Residents in University of Louisville School of Medicine residency

programs are classified as students (see item #7 in the Resident Agreement).

Clinical and educational work hours (Work Hours): defined as all clinical and academic activities related to the

residency/fellowship program. This includes inpatient and outpatient clinical care, in- house call, short call, night

float and day float, transfer of patient care, and administrative activities related to patient care, such as completing

medical records, ordering and reviewing lab tests, and signing orders.

• Hours spent on activities that are required in the accreditation requirements, such as membership on a hospital

committee, or that are accepted practice in residency/fellowship programs, such as residents’/fellows’

participation in interviewing residency/fellowship candidates, must be included in the count of clinical and

educational work hours.

• For call from home, time devoted to clinical work done from home and time spent in the hospital after being

called in to provide patient care count toward the 80-hour weekly limit. Types of work from home that must be

counted include using an electronic health record and taking calls.

• Reading done in preparation for the following day’s cases, studying, and research done from home do not

count toward the 80 hours.

Specific types of Work Hours include:

• External moonlighting: Voluntary, compensated, medically-related work performed outside the

institution where the resident is in training or at any of its related participating sites.

• In-House Call: Duty hours beyond the normal work day when residents are required to be immediately

available in the assigned institution.

• Internal Moonlighting: Voluntary, compensated, medically-related work (not related with training

requirements) performed within the institution in which the resident is in training or at any of its related

participating sites.

• Night Float: Rotation or educational experience designed to either eliminate in-house call or to assist

other residents during the night. Residents assigned to night float are assigned on-site duty during

evening/night shifts and are responsible for admitting or cross-covering patients until morning and do not

have daytime assignments. Rotation must have an educational focus.

• Home/Pager Call: call taken from outside the assigned institution by pager or phone,

Continuous time on duty: The period that a resident or fellow is in the hospital (or other clinical care setting) continuously,

counting the resident’s (or fellow’s) regular scheduled day, time on call, and the hours a resident (or fellow)

remains on duty after the end of the on-call period to transfer the care of patients and for didactic activities.

Scheduled duty periods: Assigned duty within the institution encompassing hours which may be within the normal work

day, beyond the normal work day, or a combination of both.

One Day Off: One (1) continuous 24-hour period free from all administrative, clinical and educational activities.

POLICY/PROGRAM REQUIREMENTS

1. Each sponsored training program at the U of L School of Medicine must have a formal, written policy on resident

Work Hours. The written policy must be provided to all residents and faculty. All programs must submit a copy of

the program specific written policy on Resident Work Hours to the Office of Graduate Medical Education (GME)

by loading into Med-Hub. Whenever changes are made to this document, the GME Office must have a record of

the most current policy.

2. The policy must foster resident education, facilitate patient care, and be consistent with the current published

institutional and program requirements of the specialties and subspecialties that apply to each program. The policy

must cover all institutions to which residents rotate. In the event an individual RRC publishes standards which

differ from those stated in this policy, the program should follow its published RRC standards.

a) Resident work hours must not exceed 80 hours per week averaged over four weeks which is inclusive of all in-

house clinical and educational activities, clinical work done from home, and all moonlighting.

b) Residents should have 8 hours off between scheduled clinical work and education periods. There may be

circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than

eight hours free of clinical experience and education. This must occur within the context of the 80 hour and

the one-day-off-in- seven requirements.

c) In-house call must occur no more frequently than every third night, averaged over a four-week period.

Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.

d) In-House night float must occur within the context of the 80 hour and one-day-off-in-seven requirements. The

maximum number of consecutive weeks of night float, and maximum number of months of night float per year

may be further specified by the review committees.

e) Clinical and educational work periods for residents must not exceed 24-hours maximum continuous on-site

work with up to 4 additional hours permitted for activities related to patient safety such as providing effective

transition of care, and/or resident education. There must not be additional patient care responsibilities assigned

to a resident during this time. In unusual circumstances, residents, on their own initiative, may remain beyond

their scheduled period of work to continue to provide care to a single, severely ill patient, to provide

humanistic attention to the needs of a patient or family, or to attend unique educational events. These

additional hours will be counted toward the 80-hour work week.

f) Resident time spent in the hospital or on patient care activities at home during at-home call must be counted

toward the 80-hour maximum weekly limit. At-home call is not subject to the every 3rd night limitation

however it must satisfy the requirement for one day in seven free of clinical work and education, when

averaged over four weeks. At-home call must not be so frequent as to preclude rest and reasonable personal

time for residents.

g) All residents, including those assigned at-home call, must be provided with 1 day in 7 free from all educational

and clinical responsibilities, averaged over a four-week period, inclusive of call. At home call cannot be

assigned on these days.

3. Program Directors must ensure that moonlighting does not interfere with the ability of the resident to achieve the

goals and objectives of the educational program. Resident moonlighting must be approved in advance with the

approval documented in MedHub, and monitored by the program director. Programs must implement mechanisms

to monitor resident moonlighting to ensure compliance with both program and institutional policies. All

moonlighting that occurs both within the residency program and/or the sponsoring institution or outside the

sponsoring institution must be counted toward the 80-hour weekly limit on duty hours. Moonlighting cannot be

required by the program; PGY-1 residents are not permitted to moonlight. For additional information, please see

institutional GME Policy & Procedure on Resident Moonlighting and Extra Duty Pay.

4. Work hours must be monitored by the program to assure compliance with ACGME requirements. Work hour

reporting must be completed by the resident, and not the program. On the 10

of the month, Med-Hub will lock

the prior month’s work hour activity, which makes the resident work hours unamendable for program

administrators without requesting access via the GME Office.

5. Program Directors must monitor resident well-being and develop policies for educating faculty and residents to

recognize the signs of stress and fatigue and for dealing with residents identified as stressed or fatigued.

6. The program, in partnership with its Sponsoring Institution, must ensure adequate sleep facilities and safe

transportation options for residents who may be too fatigued to safely return home.

• Sleep facilities (Call Rooms) are available at the major participating sites and access procedures varies by

program. It is the program’s responsibility to communicate this information to residents.

• The House Staff Council Uber transportation program was implemented to assist residents who feel too

fatigued or sleepy to drive home, particularly but not limited to after being on-call. The program is provided

free to UofL residents and funding is provided through the Office of Graduate Medical Education. For

additional information, please visit website:

http://louisville.edu/medicine/gme/current-residents/cab-voucher-

program.

7. Residents must at all times have appropriate support and supervision in accordance with current published ACGME

institutional and program requirements and with the School of Medicine Resident Supervision Policy & Procedure.

Programs must ensure that residents are provided appropriate back-up support when patient care responsibilities are

particularly difficult or prolonged. Each program must have a process to ensure continuity of patient care in the

event that a resident may be unable to perform his/her patient care duties, per the Transitions in Care Policy &

Procedure.

RESIDENT REQUIREMENTS

1. All residents who sign contracts through the GME Office are required to enter and submit their work hours in the

MedHub system weekly.

2. Residents have two weeks in which to document and submit work hours after which they are locked out. Lockout

occurs at 12:01am EST Sunday morning for the previous week. Residents that have failed to log and submit any

work hours for the prior week will be reminded by email and alert on their portal page. They still would have a full

week to document and submit work hours for the previous week.

3. Resident work hour timesheets include an extensive amount of information to make documenting Resident work

hours as quick and painless as possible.

• Each Resident Work Hour Timesheet includes the date, scheduled activity, in time, and out time

• A 'Submit Completed Work Hours' link that automatically calculates the entered hours against ACGME

regulations *

• Color coded calendars showing compliance history

• Automatic calculation of potential violations against ACGME regulations which automatically requires a

mitigating reason. MedHub work hour functionality is proactive rather than reactive. Activity flagged by

MedHub and requiring a mitigating reason should be considered a "potential violation" because it is calculated

against a single weekly time sheet rather than the ACGME 4-week average. When averaged, over the full

period it may result in no violation at all.

4. By design, there is no Resident unlock. Residents who have not completed documenting (logging and submitting)

their work hours prior to the deadline have been locked out of editing and submitting work hours and must go to

their residency Program Director or Administrator to have the hours logged and submitted.

PROCEDURE: MONITORING OF RESIDENT SUBMISSION OF HOURS

1. It is the programs responsibility to monitor resident submission of work hours. Programs should not rely on

communications and reminder from the GME Office.

2. The GME Office will generate a “work hours submission” report the first week of every month who have resident

that have not logged and/or submitted hours for the previous month (i.e., a report of residents who have not logged

and/or submitted hours for December will be run the first week of January).

3. Based upon the work hours submission reporting, delinquent notifications will be sent to the appropriate Program

Directors by the 5

of each month. Program Directors or Administrators are responsible for working with the

resident to have all work hours brought up to date.

4. Once the reports are distributed, residents will be given until the 10

to meet with the Program Director or

Administrator to enter and submit the missing hours before the Program Director and Administrator are also locked

out of the prior month.

5. If the resident has not successfully communicated with the Program Director or Administrator regarding entering

and submitting the missing hours by the 10

day of the month,

a) It will be recommended to the Dean that the resident be placed on academic probation, following the

Policy & Procedure for Probation, Suspension, and Dismissal. A copy of the recommendation will be

forwarded to the resident and the Program Director.

b) After the 10

, the program will need to request temporary access (for the Program Director and

Administrator) for the hours to be entered and submitted.

6. Once placed on probation, the resident will be placed on a watch list for a 60 day period to improve work hour

logging and submission practices. If not improved by the end of 60 days, a recommendation for suspension from

program activities and payroll will be forwarded to the Dean.

PROCEDURE: MONITORING OF WORK HOUR VIOLATIONS

1. It is the program’s responsibility to monitor and address work hour violations.

2. The GMEC Subcommittee titled the Resident Educational and Work Environment (REWE) Subcommittee will

meet every other month and as needed. Work hour or educational environmental concerns will be brought to and

addressed by the committee through the following channels:

a) There will be an administrative staff member of the GME office dedicated to work hour monitoring. The

Resident Education and Work Environment Coordinator (REWE Coordinator) will monitor work hour

violations across all programs and report to the Vice Dean for Graduate Medical Education & Continuing

Medical Education, as well as to the REWE Subcommittee. The REWE Coordinator will report areas where

persistent problems are noted in order for the subcommittee to work with Program Directors, Departments or

others to facilitate solutions.

b) There will be an Ombuds position within the GME office. The Ombuds will be an ad-hoc member on the

GMEC and the REWE Subcommittee. This position has the support of the Vice Dean of Graduate Medical

Education & Continuing Medical Education as well as the Dean of the Medical School. The Ombuds also

serves as the Work Hours Ombuds. Residents can raise work hour concerns with the Ombuds anonymously

and without fear of intimidation or retaliation.

3. The GMEC’s Resident Educational and Work Environment Subcommittee will report to the Vice Dean for

Graduate Medical Education & Continuing Medical Education as well as the GMEC.

4. In the event that recurrent work hour violations within a program cannot be resolved through the efforts of the

Program Director and/or Program Evaluation Committee (PEC), the REWE Subcommittee will meet to investigate

and address problems with the support of the Vice Dean for Graduate Medical Education & Continuing Medical

Education.

5. Work Hour violations must be addressed in the programs Annual Program Evaluation (APE) report submitted to

the GME Office each academic year.

REFERENCES & RELATED POLICIES

ACGME Institutional Requirements, Effective July 1, 2018, section IV.J: Clinical and Educational Work Hours: The

Sponsoring Institution must maintain a clinical and educational work hour policy that ensures effective oversight of

institutional and program-level compliance with ACGME clinical and educational work hour requirements. (Core)

ACGME Institutional Requirements, Effective July 1, 2018, section III.B.5.b): The Sponsoring Institution, in partnership

with its ACGME- accredited program(s), must ensure adequate sleep facilities and safe transportation options for

residents/fellows who may be too fatigued to return safely home. (Core)

ACGME Common Program Requirements, Effective July 1, 2017 (Section VI Changes)

Resident Supervision Policy & Procedures

Probation, Suspension, and Dismissal Due Process Procedure

Work Hour Exceptions Procedure

*Program Specific for Resident Work Hours Policy & Procedures

APPROVAL

Effective: March 19, 2008

Revised: September 15, 2010

Revised March 16, 2011 GMEC; Effective July 1, 2011

Revised April 17, 2013

Revised September 25, 2015; Approved by GMEC November 18, 2015

Revised March 27, 2019; Approved by GMEC April 1, 2019

Revised February 2020 updating Monitoring of resident submission of hours; Approved by GMEC March 31, 2020

Reviewed by REWE for recommendation to GMEC: November 3, 2021 regarding MedHub locking on the 10

instead of

the 15

each month. Accepted by GMEC: November 17, 2021

Resident Policies and Procedures

Section X.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

POLICY ON EVALUATION, PROMOTION AND TERMINATION

1. Each program director must develop guidelines for evaluation and promotion of residents to the next postgraduate

level based on ACGME and RRC standards. Residents who do not meet these criteria are subject to probation,

suspension, and dismissal.

2. The following are areas of performance that may warrant probation, suspension, and termination:

Professional Performance: Actions that endanger patients or the staff, violations of institutional policies, and

actions which are detrimental to the institution and program.

Academic Performance: Actions that display knowledge deficiencies, including the inability to perform

assignments in a manner commensurate with postgraduate-level education and the inability to apply learned skills in an

appropriate manner.

3. Residents with professional or academic performance issues which warrant review may be given several options,

including:

Performance improvement plan

Probation

Temporary Suspension

Termination from program and institution

4. Residents, whenever possible, will be given at least a four-month written notice when his/her performance is

unfavorable for promotion or the program is considering termination.

5. Residents will be afforded due process in accordance with the “Academic Probation and Due Process Policy for

Residents” and “Grievance Procedures for Residents” as published in the Resident Policies and Procedures manual.

Date of GMEC Approval: 12/17/08

Resident Policies and Procedures

Section XI.

EMAIL ACCOUNTS

UNIVERSITY OF LOUISVILLE

Email accounts of trainees who recently graduated from UL as a medical student remain active. Trainees new to

UL will need the following information to open an email account.

NOTE: All Residents/Fellows are required to open and use U of L Email Accounts. The School of Medicine purchased and

implemented a GME Management Software System, MedHub. All evaluations will be accomplished electronically and

residents must maintain an active e-mail account, keep their e-mail address updated in MedHub, and provide a correct e-

mail address to their residency program coordinator.

To access U of L email, go to outlook.office365.com and enter your UofL email and password.

User ID/Password Information for First-Time Users

Your email address is your ULink user ID @louisville.edu (for example: fmlast01@louisville.edu). Your log in ID for your

Uof L email is your ULink user ID @louisville.edu.

If you do not know your ULink user ID, you can obtain it by accessing http://louisville.edu/userid

and using your Social

Security number or the 7-digit employee ID printed on your Cardinal Card. If you have already used your university email

account, your ULink user ID will be the same as your email user ID.

If you have forgotten your password and have not set your challenge questions, your unit's Tier 1 technical support staff can

change your password or take a picture ID to a computing center for a password reset.

See this link for further information on getting started setting up U of L email: https://louisville.edu/email/

If you have any other user ID or password problems, please contact the IT HelpDesk at 852-7997, or

https://louisville.edu/its/get-help/its-helpdesk .

Resident Policies and Procedures

Section XII.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

FRINGE BENEFITS

Life Insurance

Term life insurance is provided for all residents, in the amount of $2000 of life insurance for each $1000 of annual stipend.

Accidental death and dismemberment coverage is included.

Health Insurance

Single and family coverage is available at group rates. Several different plans at varying costs are available to choose from.

Residents may choose Premium Conversion, which permits payment of premiums with pre-tax dollars. Flexible Spending

Accounts also available.

Workers Compensation

All residents are covered by workers compensation for medical expenses and lost work time due to job-related illness or

injury.

Disability Insurance

Long-term disability insurance is provided for residents, free of charge. Residents have the option of converting the

coverage from group to individual at the end of their training, and the option of purchasing additional coverage at very

reduced rates.

Malpractice Insurance

Coverage is provided for all residents by either the University of Louisville or by the hospitals to which residents are

assigned. This coverage applies to all assigned rotations that are part of residency training, as detailed on the reverse side of

the resident agreement. (See Section XIX, Malpractice Coverage).

Dental Care and Coverage

The Faculty Practice Office in the Outpatient Care Center will provide annual examination, including cleaning and up to

four bitewing x-rays, to residents free of charge. Any additional services are the responsibility of the resident. Residents

can call 852-5401 for information. Residents may also purchase, at group rates, dental insurance in both single and family

plans.

Employee Assistance Program

An Employee Assistance Program (EAP) is available to residents and fellows at no charge and provides confidential

counseling, assessment and referral services. The program deals with the broad range of issues such as

emotional/behavioral, family and marital, alcohol and/or drug, financial, legal, and other personal problems. These services

are provided by the Human Development Company.

Medical Licensure

Kentucky state law requires that all PGY-2 and above trainees be licensed to practice medicine in the state of Kentucky.

The fee for the initial training license is paid by the Graduate Medical Education Office for the PGY-1's who continue as

PGY-2's in U of L programs.

Campus Health Service Office

Hepatitis B immunization and an annual TB skin test are required and furnished free of charge to all residents. The Campus

Health Services Office provides minor urgent medical care and immunizations, including boosters and TB testing. Personal

counseling is also available. The Campus Health Services Office also serves as an on-site treatment facility for workers

compensation related injuries and exposures including needle sticks, and as the repository of resident immunization

records and exposure data. The office is staffed by board certified faculty physicians and faculty nurse practitioners

who have extensive primary care and occupational exposure experience.

Vacation (Annual Leave)

All postgraduate physicians are entitled to 28 calendar days of vacation for each twelve-month period.

Lab Coats

Lab coats are provided by departments for residents at the beginning of their training.

Library Privileges and Services

Residents have library privileges at the medical school library (Kornhauser Health Sciences Library) and at all

affiliated hospitals. Available services include electronic literature searches and interlibrary loan service.

Audiovisual equipment, as well as computers and computer software, are made available to residents through the

library. Through the Kornhauser Library’s website (http://library.louisville.edu/kornhauser/), residents have access

to thousands of electronic journals via Medline and online e-journal collections. Residents can search the library’s

catalog or view a collection of electronic textbooks and reference materials online.

Counseling Services

Professional counseling is available to residents through the Health Sciences Center Campus Health Services.

Counseling services are also available through the University of Louisville Employee Assistance Program. See

Section III.D (Campus Health Services Office) for additional counseling options.

Recreational Facilities

Free membership to the HSC Fitness Center is available to all HSC residents, students, staff and faculty. The

Fitness Center is conveniently located in the Chestnut Street Parking Garage, and includes weight machines, free

weights, and 20 pieces of aerobic equipment. Aerobics and yoga classes are also offered. In addition, a swimming

pool and recreational facilities on Belknap Campus are also available to residents, through the Intramural and

Recreational Sports Office, the Student Activities Center, and Crawford Gymnasium.

Medical and Personal Leave

Paid medical leave up to 90 days is available in cases of extended personal illness. Residents are covered under the

Graduate Medical Student Leave Policy, which provides up to 12 weeks unpaid leave for personal or family illness.

Personal leave is available at the discretion of the Program Director.

Maternity/Paternity Leave

Residents are allowed up to 42 days of paid post-partum leave.

Lactation Rooms

Lactation rooms are at various locations on the Health Sciences Campus. Current locations available at

https://louisville.edu/womenscenter/resources/lactation-information

Health Care and Dependent Care Flexible Spending Accounts

Residents may establish accounts to convert tax-free benefit dollars within the limits established by the IRS.

Flexible spending accounts provide pre-tax dollars to be used toward medical, dental, vision, pharmacy, and daycare

expenses. The monies are reimbursed to the resident for expenses incurred.

Parking

Parking permits are provided to residents by either their program or the GME office at no cost to the resident.

Retirement Plan

The University of Louisville House Staff are eligible to participate in the 403(b) retirement plan by electing to

contribute to the voluntary Employee Supplemental and Roth Additional options. The contributions in the

Employee Supplemental and Roth Additional options are not matched by the University.

Greater Louisville Medical Society Membership

The Graduate Medical Education office greatly encourages residents to contribute to their community and improve

the future of their profession through leadership and advocacy. In that spirit, the Graduate Medical Education Office

is providing membership to the Greater Louisville Medical Society (GLMS) and the Kentucky Medical Association

(KMA) at no cost to GME contracted residents and fellows.

Uber Transportation Program

An Uber based transportation service is provided free of charge to U of L residents/fellows.

The purpose of this program is to ensure that all residents & fellows have a safe transportation option if they are too

fatigued to return home safely.

Other Benefits

Some departments provide additional benefits to their residents, such as textbooks, professional dues, or funds for

travel to educational meetings.

Resident Policies and Procedures

Section XIII.

Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act (“HIPAA”) was passed in 1996. HIPAA incorporates

several legislative actions. Title I involves issues surrounding the availability, portability and renewability of health

insurance. Title II contains changes to fraud and abuse laws and the Administrative Simplification Section. Title III

contains tax provisions; Title IV contains application and enforcement provisions of group health plan regulations

and Title V contains revenue offsets. The Administrative Simplification Section of Title II is the section that

triggered the regulations for standard transactions and code sets, privacy and security of health information, and

unique health identifiers.

HIPAA changed the way health information is shared among the players in the health care market. Not only

did the privacy requirements of HIPAA change the role of the physician by making what was once an

unregulated responsibility to protect patient privacy into a legal obligation, but the method by which health

information is maintained and transmitted also changed. Most physicians are impacted by the Administrative

Simplification Section of HIPAA in virtually every aspect of their daily practice.

Required Trainings

The University of Louisville requires the following training for residents. Instructions for access to the

trainings is included below.

• HIPAA Privacy (required annually)

• Responsible Conduct of Research (all disciplines now in one course)

• Conflicts of Interest (included in the Attestation and Disclosure Form)

• Institutional Compliance Awareness (included in the Attestation and Disclosure Form)

The following trainings may be required for residents working in research:

• Human Subjects & HIPAA Research (required every 4 years). This training module is required for

individuals to be added to a study team for research that requires IRB oversight.

• Export Controls. Training related to export controls is required should the nature of the research involve

controlled items.

• IACUC: OSHA. This training is required if the research involves animals.

To access HIPAA Privacy training:

1. Go to website https://louisville-ky.safecolleges.com. (Your login/password is your University

2. Choose the “HIPAA Overview” module. (NOTE: you may have to scroll down to see the

module).

3. Upon completion of all Required Modules and achieving 80% overall correct score, a link

will appear to access your completion certificate. Keep a copy of this report for your

records.

To access courses on the CITI platform such as, Human Subjects & HIPAA Research, Responsible Conduct

of Research, Export Controls, and IACUC trainings:

1. Go to CITI website www.citiprogram.org

2. Returning Users: Sign in on the home screen. Select University of Louisville Courses. Proceed to Step

3. New Users: click on ‘Register’ under ‘Create an Account.’ Select Your Institution or Organization:

Under ‘Search for organization:’ enter ‘University of Louisville’.

4. Personal Information: Enter your first and last name, as recorded with the university. Under email use your

U of L email (userid@louisville.edu) as the email address. You can add another preferred address to the

Secondary email address field, if you like. If you do not use your primary U of L email address (not your

PEA) in the first email field, your training results could be delayed in posting to iRIS. Please note: the

email addresses entered here are the ones that any future password requests will be sent to; you are

encouraged to use addresses that are stable and make sure to enter them without any typos.

5. Create Your Username and Password: Follow the instructions on the page regarding size and criteria. The

Username and Password can be anything of your choosing that is accepted by the system.

6. Gender, Ethnicity and Race: Enter your answers to the questions on the screen. While you are required to

answer the questions, there is an option of no disclosure, if you prefer.

7. Are you interested in the option of receiving Continuing Education Unit (CEU) credit for completed CITI

Program courses? Answer ‘No’. Can CITI Program contact you at a later date regarding participation in

research surveys? Answer ‘No’.

8. Information requested by U of L: Complete the demographic information. Fields that are marked by an

asterisk are required by the system. Enter your University of Louisville Student ID # in the Employee

Number field. Enter ‘School of Medicine’ in the Department field. Select any role in research (they are

removing this field.) Enter your cell phone number in the Office Phone field.

9. Select “Add a Course” from the “My Learner Tools for University of Louisville.” Select ‘I know what I

need to take, just show me the full menu of courses. Click ‘Next’.

10. Check: Select the course you want to take. Click ‘Next’.

11. Click ‘Finalize Registration’. You will be directed a menu with the courses you need to complete.

12. Click on the course(s) name to begin the training. For each course, click on ‘The Integrity Assurance

Statement ‘, ‘Agree’, and ‘Submit’ before beginning the course. You must do this for each course.

13. Upon completion of all Required Modules and achieving 80% overall correct score, a link will appear on

the Grade Book page with your Completion Report. Keep a copy of this report for your records.

Questions or comments regarding the content of the HIPAA Privacy training should be directed to the Privacy

Office at 502-852-3803 or via email at privacy@louisville.edu .

Questions or comments regarding the content of the Human Subjects & HIPAA Research training should be directed

to the Human Subjects Protection Program Office at hsppofc@louisville.edu. Information is also available on the

HSPPO homepage under “Study Personnel Requirements.”

Questions or comments regarding the content of the Responsible Conduct of Research, Export Controls, and IACUC

trainings should be directed to the Office of Research Integrity Office at ori@louisville.edu

Revised 05/20/2004; 04/20/05; 02/2006; 04/2007; 03/2008; 4/2010; 2/2011; 4/2015, 3/2020, 3/2022

Resident Policies and Procedure

Section XIV.

HOUSE STAFF COUNCIL

The purpose of the House Staff Council is to serve as an avenue for the concerns and problems of U of L residents

and fellows, disseminate information applicable and helpful to all residents, and promote U of L residents as a

unified group. This organization, which is comprised of peer-selected representatives from each training program,

meets monthly to plan professional development and social events, schedule speakers, and address problems and

concerns as they arise. Representatives selected from this council serve on the Graduate Medical Education

Committee, Academic Grievance Committee, Faculty Forum, and Medical Council. The House Staff Council also

publishes a website to keep residents informed about issues of interest to them.

2023-2024 House Staff Council President

Michael Rocklin Schumaker, MD Radiology

2023-2024 House Staff Council Members

Program Name

Anesthesiology TBA

Dermatology Danielle Perma

Emergency Medicine Alex Edwards, Luke Daniel

Family Medicine Filipe De La Barra, Bachar Hadaie

Internal Medicine Danielle Jayanty, Aangi Shah, Aishwarya Thakurdesai

Medicine/Pediatrics Shelby Falkenhagen, Lucas Banter

Neurology Mohammad Ghani

Child Neurology Jake Ritchie, Max Gallivan, Erika Chandler

Neurosurgery Nick Deitz, Raja Jani

Obstetrics/Gynecology TBA

Ophthalmology Elizabeth Dugan, Erich Berg

Oral Surgery Nathan Domborski, Nashwin Laugani

Orthopaedic Surgery Mike Sirignano, Rahool Bhimani

Pathology TBA

Pediatrics Victoria Thompson, Kristin Schutzman, Abby Gellert

Peds Neonatology Julie Springate-Spalding

Peds Child Abuse TBA

PM&R Sam Kimmell, Brooke Madson

Psychiatry TBA

Radiology Rocklin Schumaker, Adam Richardson

Surgery TBA

Urology TBA

Resident Policies and Procedures

Section XV.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

ADDRESSING IMPAIRED RESIDENTS & SUBSTANCE ABUSE PROCEDURE

BACKGROUND (INTENT)

The University of Louisville is committed to protecting the safety, health and well-being of all students, residents,

faculty and staff and other individuals in our workplace. We recognize that alcohol abuse and drug use pose a

significant threat to our goals. We have established a drug-free workplace program that balances our respect for

individuals with the need to maintain an alcohol and drug-free environment. As a recipient of federal grants and

contracts, the university gives this notice to students, faculty and staff that it is in compliance with the Drug-Free

Workplace Act of 1988 (Pub. L.100-690, Title V Subtitle D) and the Drug-Free Schools and Communities Act

Amendment of1989.

DEFINITIONS (AS USED IN THIS DOCUMENT)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows. Residents in University of Louisville School of Medicine

training programs are classified as students (see item #7 in the Resident Agreement).

PROCEDURE

1. Residents who exhibit signs of impairment due to substance abuse are referred to the Kentucky Physicians

Health Foundation (KPHF) for evaluation in accordance with Kentucky medical licensure laws. KPHF

evaluates and monitors impaired physicians for the Kentucky Board of Medical Licensure (KBML) under a

formal contractual arrangement. The University follows the recommendations of this organization for the

treatment and monitoring of impaired residents as well as the written policies of the University of

Louisville Hospital.

2. As residents begin training in University programs, they are required to complete a Hospital Privileges

Application, which requires information about their personal health status and includes questions related to

impairment due to alcohol and other drugs. These applications are reviewed by the hospital Physicians

Health Committee (PHC), which in turn makes recommendations to the hospital Credentials Committee.

3. Residents who are in recovery are reviewed at quarterly meetings of the PHC. There is formal written

exchange of information about the status of the resident’s recovery between the PHC and the KPHF

quarterly.

4. Residents who are found to be impaired because of known and untreated substance abuse, or who violate

the Kentucky licensure law are referred to the KBML as required by law.

5. Residents needing assistance or who have questions should contact their Program Director, the Medical

Director of the Kentucky Physicians Health Foundation (Dr. Greg Jones at 425-7761), or the Chairman of

the University of Louisville Hospital’s Physicians Health committee (Dr. Christopher Stewart at 813-6626).

References & Related Policies

ACGME Institutional Requirements, Effective July 1, 2018 (IV.H.2.)

UofL GME Resident Supervision Policy & Procedures

UofL Policy Statement as a Drug-Free Institution on the Human Resources web site:

http://louisville.edu/hr/policies/the-university-of-louisville-policy-statement-as-a-drug-free-institution

Approval

Revised: March 10, 2000, July 2003, May 2004, October 2018 (formatting only),

Revised with GMEC approval: March 31, 2020

Section XVI.

Resident Policies and Procedures

Section XVI

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

FOREIGN NATIONALS AND INTERNATIONAL MEDICAL GRADUATES

POLICIES AND PROCEDURES

DEFINITIONS (AS USED IN THIS DOCUMENT)

Educational Commission on Foreign Medical Graduates (ECFMG): ECFMG is a private, non-profit

organization established to:

• provide information to and answer inquiries of IMGs planning to come to the United States for GME;

• evaluate IMGs’ credentials, knowledge of medicine, and command of English; and

• certify that IMGs have met certain medical education and examination requirements.

Certification by ECFMG is the standard for evaluating the qualifications of International medical graduates

(IMGs) before they enter U.S. graduate medical education (GME), where they provide supervised patient

care. ECFMG Certification also is a requirement for IMGs to take Step 3 of the three-step United States

Medical Licensing Examination® (USMLE®) and to obtain an unrestricted license to practice medicine in

the United States. (From https://www.ecfmg.org/about/index.html

, accessed September 4, 2020)

ECFMG also administers the Exchange Visitor Sponsorship Program (EVSP), which sponsors J-1 visas for

the purpose of participation in a U.S. accredited training program. For more information and a complete

listing of services provided to assist IMGs, please go to the ECFMG website www.ECFMG.org

or contact

Kathy Sandman in the GME Office.

Employment Authorization Documents (EAD): A document issued by the United States Citizenship and

Immigration Services (USCIS). See

https://www.uscis.gov/working-in-the-united-states/information-for-

employers-and-employees/employer-information/employment-authorization for more information.

International medical graduates (IMGs): A physician who has graduated from a medical school outside of the

United States or Canada.

POLICY

1. Individual programs may limit the amount of time they will hold a position open for applicants to obtain

appropriate immigration status.

ECFMG Certificate Requirement for IMGs

2. All graduates of medical schools outside of the United States or Canada must have a valid ECFMG

certificate to train in University of Louisville residency programs.

3. Certificates must be current on the date that the resident begins training.

Foreign Nationals Employment Authorizations/Immigration Status

4. Foreign medical residents may train using a Permanent Resident Card (Green Card) or Employment

Authorization Documents (EAD) or by obtaining an accepted via status.

a. Visas Accepted:

i. J1 Clinical Visa: The University of Louisville School of Medicine utilizes the J1 visa for

residency training. Eligibility criteria for the J1 visa include ECFMG sponsorship and

acceptance into an ACGME-accredited Residency or fellowship program or any program

approved by the ECFMG.

i. Residents sponsored on J1 visas are not allowed to moonlight or earn any income for

activities that are not a part of their training program.

b. Visas Not Accepted:

i. H1B Visas: Because residents are classified as students at the University of Louisville, the

University does not sponsor H1B visas for residency training.

ii. J2 Dependent Visas: J2 dependent visas are not accepted for residency training. These

individuals must obtain their own J1 visa status.

iii. J1 Research Visa: The J1 research visa does not allow the clinical activity required for

residency training programs. Those applicants currently sponsored on the J1 Research visa

must apply for a change of category to J1 Clinical, which requires Department of State

approval.

5. It is the resident’s responsibility to see that these documents are renewed when appropriate; allowing these

documents to expire can result in a lapse in training.

6. The GME office must have a copy of the unexpired document on file in order for the resident to train and

be paid.

7. All residents training on visas are required to provide a copy of their most recent I-94 in order to begin

training.

PROCEDURE

J1 Visa Application and Renewal Instructions

1. The Training Program Liaison initiates the application. The applicant submits the application and

coordinators with the TPL to submit required documents.

2. Under normal circumstances applications take 4-6 weeks to be approved, but it is recommended that

applications be sent as early as possible to avoid delay due to unforeseen complications.

3. The deadline for submitting applications for initial sponsorship to the ECFMG is April 1.

4. Applications for continuing sponsorship should be submitted by May 1.

Foreign Nationals Employment Authorizations/Permanent Resident Card Instructions

5. It is the resident’s responsibility to see that these documents are renewed when appropriate to avoid any

lapse in training.

6. We recommend that applications for renewal of Permanent Resident cards be submitted 5-6 months before

the expiration date.

7. Applications for Renewal EAD’s should be submitted at least 90 days in advance of expiration.

8. Trainees should notify the GME Office if there is any change in immigration status.

CONTACT

Kathy Sandman

Office of Graduate Medical Education

(502) 852-3135

APPROVAL

05/2004. Revised 04/20/05; 3/20/2008; 3/4/09, 2/17/2021

Resident Policies and Procedures

Section XVII.a

UNIVERSITY OF LOUISVILLE GRADUATE MEDICAL EDUCATION

RESIDENT LEAVE OF ABSENCE POLICY & PROCEDURE

BACKGROUND (INTENT)

As an Accreditation Council for Graduate Medical Education (ACGME) Sponsoring Institution, the University of

Louisville’s School of Medicine must have a policy for vacation and other leaves of absence, consistent with

applicable laws (ACGME Institutional Requirement IV.G.1). A separate policy document addresses resident

vacation.

DEFINITIONS (AS USED IN THIS POLICY)

Calendar day: all 365 days in a year, including weekends and holidays.

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows. The term “resident” in this document refers to both

specialty residents and subspecialty fellows.

1. Program Directors are responsible for assuring that all leaves of absence are granted in accordance with

institutional, ACGME, and certifying board eligibility requirements. Should this policy be in conflict with

the respective ACGME or Board Certification requirements, those requirements will take precedence.

a. Any leave of absence must be in compliance with the ACGME Program Requirements concerning

the effect of leaves of absence, for any reason, on satisfying the criteria for completion of the

residency program.

b. The leave must also be in compliance with the eligibility requirements for certification by the

appropriate certifying board for the specialty.

2. Leaves of absence may require additional training time to fulfill ACGME and/or Board Certification

requirements. Program Directors are responsible for determining, in accordance with RRC and Board

requirements, how much time must be made up. Program Directors must inform residents in writing, using

the Resident Leave of Absence Request Worksheet, of any make-up time required.

It is the responsibility of the resident and Program Director to discuss, in advance, information regarding the impact of

an extended leave of absence upon the criteria for satisfactory completion of the program and upon a resident’s

eligibility to participate in examinations by the relevant certifying board(s).

• The GME sets parameters for paid time off limits; however, this does not guarantee that board eligibility will not be

impacted by the duration of paid time off or the duration of paid or unpaid leave.

• Each program must consult the American Boards of each specialty to determine whether the resident remains Board

eligible or whether a training extension is necessary. As guidelines vary widely across Boards, each Board must be

consulted to ensure compliance.

o If total time away from training (within a given PGY or through the duration of the training program) extends

beyond the maximum allowed by the specialty Board, and makeup time is required, the trainee's reappointment

dates may be delayed by an amount equal to the makeup time (i.e., delay of promotion to the next PGY level or

program completion). In effect, all future training years would become off-cycle by an amount equal to the

makeup time. Any required makeup time will be paid and all fringe benefits provided.

a. If residents are required to make-up time missed, that time must be covered by a Resident

Agreement, with the resident being paid at the appropriate Resident Level and all fringe benefits

provided.

3. The GME Office sets parameters for paid time off limits. A leave of absence may be paid, unpaid or a

combination of paid and unpaid. Pay status of the leave does not impact board eligibility nor if a training

extension is necessary.

a. Paid leave time may be taken intermittently following the initial leave event, at the discretion of

the Program Director. A separate leave worksheet must be completed for each segment.

TYPES OF LEAVE

Caregiver Leave

1. Definition of Caregiver Leave: leave granted to care for the resident’s spouse, child, or parent who

has a serious health condition.

2. Eligibility:

a. Must be taken for the purpose of caring for a spouse, child, or parent

b. There is no minimum duration of service requirement and eligibility will start on the day the

resident is required to report (orientation date or the first day of payroll for the

resident).

c. If the resident is also Resident/Family Leave eligible, Resident/Fellow Family Leave will run

concurrently with Caregiver Leave.

3. Salary & Benefits:

a. 100% of salary for up to six weeks (42 calendar days) is guaranteed only for the first instance of

caregiver leave within a program. Subsequent leaves may be partially paid using any combination of

eligible available vacation and program director discretionary leave. Once this time is exhausted, the

resident may be permitted to take additional time off without pay up to a total of twelve (12) weeks of

leave per academic year under Resident/Fellow Family Leave.

b. Full health and disability insurance continue while the resident is on paid leave for six weeks (42

calendar days). Once the resident is on leave without pay status, the university will continue to provide

his/her health benefits, provided the resident pays the portion of the premiums that normally would

come out of his/her paycheck. Residents must check with U of L Human Resources Department to

determine the status of the health insurance benefits during unpaid leave of absence and make

arrangements for continuity of health insurance benefit coverage.

4. Funding: A resident may be paid during the leave by utilizing any unused vacation days (up to 21 calendar days

per contract year). Additionally, residency Program Directors may allow up to two additional weeks (14

calendar days) of paid leave per contract year (Program Director’s Discretionary Leave). One additional week

of GME paid leave may be utilized. By utilizing 21 days of annual vacation leave and granted two weeks of

discretionary time by the Program Director, and one week of GME paid leave, the resident can achieve a six-

week (42 calendar days) paid leave

a. If the resident has taken less than one-week of vacation time in the current academic year prior to

the beginning of the leave, they will be eligible to take additional vacation days separate from the

leave, up to the point where the one-week total of vacation has been taken during the current PGY.

b. If one-week of vacation has been taken prior to leave, additional vacation time will not be granted.

c. In the event the resident has taken more than one-week of vacation in the current academic year

prior to their leave, the program should contact the GME Office for review and consideration of

additional funding.

Educational or Personal Leaves (Program Director Discretionary Leave)

(if allowed by the RRC or Board)

1. Definition for Educational or Personal Leaves (Program Director Discretionary Leave): leave granted for

educational or personal reasons

2. Eligibility: At the discretion of the Program Director, a maximum of 14 calendar days of educational or

personal leave may be granted to the Physician per academic year.

3. Salary & Benefits

a. If approved by the Program Director, 100% of salary for up to 14 calendar days will be paid.

b. Full health and disability insurance continue while the resident is on paid leave for up to 14 days.

4. Funding: a resident is paid during the leave at the normal stipend and PGY levels

5. Requests for personal leave of absence for a period longer than 14 calendar days must be approved by the Vice

Dean for Graduate Medical Education.

6. Educational and personal leave may vary by program according to departmental guidelines, RRC/ACGME

requirements, and/or board certification requirements.

Medical (Sick) Leave, excluding Parental (Maternity/Paternity) Leave

1. Definition: Medical (Sick) Leave shall be defined as any medical condition of the individual resident, including

complications of pregnancy up to time of delivery which necessitates an absence from a resident’s training

program.

2. Eligibility:

a. Available to residents with a serious health condition that makes the resident unable to perform

essential training functions.

b. There is no minimum duration of service requirement and eligibility will start on the day the

resident is required to report (orientation date or the first day of payroll for the resident).

c. An additional period of paid medical leave for any prolonged injury or illness may be requested in

writing by the Program Director and Department Chair and submitted for approval by the Vice

Dean for Graduate Medical Education.

d. If the resident is also Resident/Family Leave eligible, Resident/Fellow Family Leave will run

concurrently with Medical Leave.

3. Salary & Benefits:

a. 100% of salary for up to 90 days is guaranteed only for the first instance of medical leave within a

program. Subsequent leaves may be partially paid using any combination of eligible available

vacation and program director discretionary leave. Once this time is exhausted, the resident may

be permitted to take additional time off without pay up to a total of twelve (12) weeks of leave per

academic year under Resident/Fellow Family Leave.

b. Full health and disability insurance continue while the resident is on paid leave for 90 days.

c. After 90 calendar days of total paid medical leave, leave of absence without pay will begin. Once

the resident is on leave without pay status, the university will continue to provide his/her health

benefits, provided the resident pays the portion of the premiums that normally would come out of

his/her paycheck. Residents must check with U of L Human Resources Department to determine

the status of the health insurance benefits during unpaid leave of absence, and make arrangements

for continuity of health insurance benefit coverage.

d. The Resident Disability Program begins its coverage 90 calendar days from the date of initial

disability. Residents who require more than 90 calendar days for medical leave should apply for

disability coverage as soon as they become aware that they will need more than 90 days.

Applications for resident disability coverage should be requested from the Graduate Medical

Education Office. If disability is denied or the individual requests leave of absence without pay,

the University is not responsible for reimbursement while in this status.

4. Funding: A resident may be paid during the leave for a maximum of 90 days by utilizing any unused vacation

days (up to 21 calendar days per contract year) and Program Director Discretionary Leave, and GME approved

leave. The resident is expected to apply for disability coverage for leave beyond 90 days.

5. Residents on medical leave for more than seven consecutive calendar days must furnish a physician's or medical

provider’s statement to the Program Director that he/she cannot work for medical reasons. The resident may be

requested to provide additional statements at any time during the leave and upon return must furnish a physician

or medical provider's statement that he/she is medically fit to resume residency training.

6. The Program Director must inform the Vice Dean for Graduate Medical Education in writing of any medical

leave of more than seven (7) calendar days. This notification must include an explanation and a completed

“Request for Leave” worksheet (available from the Graduate Medical Education Office).

7. Any modifications of duty assignment related to a medical condition or returning to duty after illness, will be at

the discretion of the Program Director and Department Chair, but must conform to state and federal laws

relating to disabilities, if any.

Military Leave*

1. Definition of Military Leave: A resident ordered to uniform service,

2. Eligibility: upon presentment of military orders to his/her program director, a resident must fill out a Resident

Leave of Absence Request Worksheet and be placed on military leave.

3. Salary and Benefits: While on military leave, the resident shall receive up to 14 calendar days of paid leave in a

federal fiscal year (This is equivalent to the Program Director’s Discretionary time). All other military leave

shall be unpaid.

a. However, at the resident’s option, the resident may request use of annual leave vacation time in

order to remain in pay status. The resident may not be required to use vacation time.

4. While on military leave, the resident is entitled to reemployment without loss of position in the

residency/fellowship program.

5. A resident requesting Military Leave should refer to the University of Louisville Policy on Military Leave.

(https://louisville.edu/policies/policies-and-procedures/index_policies

)

Parental (Maternity/Paternity) Leave

1. Definition of Parental Leave shall be defined as leave following birth to bond with a newborn, new adoption or

foster placement of a child, or granting of legal guardianship of a minor child.

2. Eligibility:

a. Available to birthing and non-birthing parents, adoptive/foster parents, surrogates, and legal

guardians.

b. Must be taken within one year of birth, adoption, foster placement, or granting of legal

guardianship of a child.

c. The birth, adoption, foster placement, or granting of legal guardianship must occur on or after the

resident’s report (orientation) date or first day on payroll.

d. There is no minimum duration of service requirement and eligibility will start on the day the

resident is required to report (orientation date, or the first day of payroll for the resident).

e. If the resident is also Resident/Family Leave eligible, Resident/Fellow Family Leave will run

concurrently with Parental Leave.

3. Salary & Benefits:

a. 100% of salary for up to six weeks (42 calendar days), per event. Additional time may be

approved by the Program Director and would be paid via a combination of vacation time, Program

Director Discretionary Leave, and unpaid leave under the Resident/Family Leave Policy.

b. Full health and disability insurance continue while the resident is on paid leave for six weeks (42

calendar days). Once the resident is on leave without pay status, the university will continue to

provide his/her health benefits, provided the resident pays the portion of the premiums that

normally would come out of his/her paycheck. Residents must check with U of L Human

Resources Department to determine the status of the health insurance benefits during unpaid leave

of absence and make arrangements for continuity of health insurance benefit coverage.

4. Funding: A resident may be paid during the leave at their current stipend level for 42 calendar days. Residents

may request additional leave time beyond 42 days by using approved vacation leave (up to 21 days), Program

Director Discretionary Leave (up to 14 days), or unpaid days.

5. Residents requiring additional leave due to complications of pregnancy or delivery should refer to the Medical

Leave section. In cases of extended Medical leave (90 days or greater) residents should contact the resident

disability insurance carrier to initiate a possible claim, or request an application from the GME Office.

Resident/Fellow Family Leave

1. Definition of Resident/Fellow Family Leave: Similar to the Federal Family and Medical Leave Act (FMLA),

the Resident/Fellow Family Leave program allows qualified residents (male or female) to take up to 12 weeks

(84 calendar days) of unpaid leave each year with no threat of job loss.

2. Eligibility: Residents who have been enrolled in a training program for one year and have worked 1,250 hours

in the 12 months prior to leave are eligible for resident/fellow family leave.

a. Qualifying events include the birth of a newborn, the adoption of a child or newborn, taking a

state-approved foster child into one’s home, time off to care for a parent, spouse or child under 18

with a serious health condition, and time off to care for children who are older than 18 if they are

unable to care for themselves, because of either mental or physical reasons. It will not, however,

allow resident/fellow family leave time for the care of parents-in-law, or other relatives.

b. Resident/fellow family leave does not cover time off for, among other things: the care of a parent-

in-law; death in the family; cold, flu, earaches, upset stomach, minor ulcers, headaches other than

migraine, routine dental and orthodontia problems, periodontal disease or cosmetic treatments.

3. A resident may take intermittent leave or work on a reduced leave schedule where he/she works fewer hours a

day or week than normally scheduled. The schedule should be designed to cause the minimum amount of

disruption to the training program as is possible.

4. Resident/fellow family leave cannot exceed 12 weeks (84 calendar days), but GME may also provide for

situations that go beyond the 12 weeks (84 calendar days). Additional information about extended leave is

available from the Graduate Medical Education Office. Any time that exceeds available vacation/PD

discretionary time will be unpaid time.

5. Exclusion: If both spouses are enrolled in U of L training programs, they are entitled to only 12 weeks of

graduate medical student leave combined for the birth and care of a newborn or the placement of a child in their

home. Otherwise, they are entitled to 12 weeks each.

PROCEDURE

1. For any Leave of Absence, a Resident Leave of Absence Request Worksheet or a Parental Leave of

Absence Worksheet (available from the Graduate Medical Education Office) must be completed and signed by

the Program Director and resident (if available) and approved by the Vice Dean for Graduate Medical

Education .

a. Program Directors must inform residents in writing, using the Resident Leave of Absence Request

Worksheet, of any make-up time required. If residents are required to make-up time missed, that

time must be covered by a Resident Agreement,

2. After approval by the Vice Dean of GME, the Leave of Absence will be recorded in the institutional Residency

Management System, MedHub, by the Administrator of the Program. The Leave of Absence will become part

of the resident’s official training record. MedHub allows for documentation of four types of resident absences:

Vacations, Sick Days, Away Conferences, and Leaves of Absences. See Guidelines for MedHub Use document

for more information.

REFERENCES & RELATED POLICIES

ACGME Institutional Requirements, Effective July 1, 2022, section IV.H.

Resident Vacation Policy & Procedure

APPROVALS

Approval of this policy will replace all prior leave policies. Approved by GMEC: April 1, 2019. Revised January 20,

2021 to allow a medical provider statement under Medical Leave. Revised February 17, 2021 to clarify PD

Discretionary Leave limitations.

Revised and GMEC approval March 24, 2022 effective July 1, 2022. Revision and GMEC approval May 15, 2023

effective July 1, 2023.

Resident Policies and Procedures

Section XVII.b

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

POLICY & PROCEDURE FOR RESIDENT VACATION

BACKGROUND (INTENT)

As an Accreditation Council for Graduate Medical Education (ACGME) Sponsoring Institution, the University of

Louisville’s School of Medicine Graduate Medical Education Office must have a policy for vacation and other

leaves of absence, consistent with applicable requirements. A separate policy document addresses other leaves of

absence.

DEFINITIONS (AS USED IN THIS POLICY)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows. The term “resident” in this document refers to both

specialty residents and subspecialty fellows.

Averaging of Work Hour rules: If a resident takes vacation or other leave, ACGME requires that vacation or leave

days be taken out of the numerator and the denominator for calculating work hours, call frequency or days

off (i.e., if a resident is on vacation for one week, the hours for that rotation must be averaged over the

remaining three weeks).

Calendar day: all 365 working days in a year, including weekends and holidays.

POLICY

1. All postgraduate physicians shall be entitled to 28 calendar days, see definition above, of vacation for each

twelve-month period.

2. Vacation time shall be prorated for employment periods of less than 12 months.

3. There is no reimbursement for unused vacation leave.

4. Vacation days cannot be carried over into or borrowed from another contract year unless requested in writing by

the resident and approved in advance by the Program Director.

5. Each training program must have a program-specific policy which is consistent with this GME policy and

defines the program’s processes of requesting, approving, scheduling and accurately documenting, in MedHub,

the residents’ vacation days. Approval of vacation time for residents is the responsibility of the Program

Director.

a. The program-specific policy must be posted in MedHub, making it available to residents and the GME

Office.

6. Should this or the program-specific policy be in conflict with ACGME or Board certification requirements, the

ACGME or Board requirements will take precedence.

7. This general policy for vacations is subject to modification in certain programs upon approval by the Vice Dean

for Graduate Medical Education or his representative.

PROCEDURE

1. Programs must set up MedHub Program Settings consistent with their program-specific policy.

a. Setting options include blocking dates/rotations on which vacation is not allowed to be scheduled ,

whether the resident or administrator will initiate the request, and the work-flow process for

approval (service head, program director, etc.).

b. MedHub functionality requires the final approval be documented by the administrator.

2. In keeping with documentation best practices and MedHub functionality, all vacation and other absences

must be approved prior to the 15

of the following month and the MedHub workflow lockout.

a. For instances where a vacation or other absence was not documented by the 15

of the following

month, the program must communicate with the GME Office as soon as possible for the system to

be corrected.

REFERENCES & RELATED POLICIES

ACGME Institutional Requirements, Effective July 1, 2018, Section IV.G.: The Sponsoring Institution must have a

policy for vacation and other leaves of absence, consistent with applicable laws. (Core)

Policy & Procedure on Resident Leave of Absence

APPROVALS

Undated

Revision approved by GMEC: March 20, 2019

Revision approved by GMEC: April 1, 2019

Resident Policies and Procedures

Section XVIII.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

RESIDENT MALPRACTICE COVERAGE

1. COVERAGE

Residents on rotation at UofL Health, Inc. facilities and other sites approved by the UofL Graduate Medical

Education Committee (GMEC) and KMRRRG for training in Kentucky are

covered by malpractice insurance purchased by the University with annual limits of $250,000 per

claim/$750,000 aggregate claims per resident. In order to qualify for this coverage the resident must

complete the required application, be accepted by the company, and comply with the terms of the policy

issued by the company. This coverage does not apply to moonlighting activities.

Affiliated teaching hospitals (Veterans Affairs Medical Center, Norton Healthcare owned or operated

facilities) provide insurance coverage for Physicians rotating there. Physicians may also purchase

additional liability insurance at their own expense.

2. DUTIES OF PHYSICIANS/REPORTING OF INCIDENTS OR SUITS

Any Physician shall report all incidents to the malpractice carrier and to the risk manager of the facility in

which the incident took place. The Physician shall assist the training facility and the insurer in the

preparation of the defense of a claim, in the conduct of any suit or the settlement thereof, including, but not

limited to meeting with counsel, attending depositions, trials, hearings and securing and giving evidence.

In connection with this cooperation and assistance, the Physician is expected to bear all his/her own

personal expenses, including without limitation, the Physician’s travel expenses for any necessary travel by

him/her, such as transportation, meals and lodging, and any lost income to the Physician for the attendance

at depositions, hearings, trials, or the preparation therefore. The Physician shall also inform Graduate

Medical Education Office and the insurance carrier of any changes in the Physician’s home or business

address and home or business telephone number.

3. TYPE OF COVERAGE

The coverage provided is occurrence based coverage (meaning that tail coverage is built into the coverage);

therefore, graduating or other residents who leave a program do not need to purchase tail coverage.

4. CONFIRMATION OF COVERAGE

Residents and fellows who need confirmation of malpractice coverage through the University must make

the request through the KMRRRG office. The request must contain the resident’s name, dates of service,

and the name and address of the person needing the confirmation. For loss run requests, a written request is

required, signed by the physician approving the release of information. Telephone requests will not be

accepted because the Physician’s signature is required in order to release the information. Requests can be

faxed to 502-569-2061. Properly submitted requests can usually be answered within 3 business days.

CONTACTS

For claims 2005 and later For claims prior to 2005 For claims prior to 2005

Melissa Updike, Executive Dir. Stephanie Curtis Office of University Counsel

Jennifer Armstrong, Sr. Claims Analyst Office of Risk Management 206 Grawemeyer Hall

Whitney Kramer, Sr. Claims Analyst And Insurance University of Louisville

10200 Forest Green Blvd, #605 University of Louisville Louisville, KY 40292

Louisville, KY 40223 (502) 852-6926 (502)852-6981

(502) 569-2060

(502) 588-7796 Fax www.kmrrrg.com

Revised 3/7/23

Resident Policies and Procedures

Section XIX.

UNIVERSITY OF LOUISVILLE GRADUATE MEDICAL EDUCATION

LICENSURE REQUIREMENTS AND PROCESS

Definitions (As used in this Document)

KBML / Kentucky Board of Medical Licensure: The Kentucky Board of Medical Licensure (KBML) is responsible

for protecting the public by ensuring that only qualified medical and osteopathic physicians are licensed and

initiating disciplinary action when violations of the Medical Practice Act occur.

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows. Note: The term “resident” in this document refers to both specialty

residents and subspecialty fellows. Residents in University of Louisville School of Medicine residency programs are

classified as students (see item #7 in the Resident Agreement).

Guidelines

1. PG Y-1 residents in Kentucky are not licensed.

2. However, in instances where a resident appointed to a PGY-1 position has completed one year of

accredited training, the resident must obtain licensure.

3. Incoming residents and fellows appointed at PGY-2 and above are required to have a valid Kentucky

license before they begin training.

a. Once matched, these individuals should email Kathy Sandman, who will forward instructions on

the licensure process.

b. Incoming trainees are responsible for applying for their own license and following up to make sure

the license is issued on time.

c. Incoming trainees are expected to apply for the most advanced license (FT, IP, R, or Full) that

they are eligible for.

4. The GME office coordinates the licensure procedure for residents who complete their PGY-1 year at UofL

and who are continuing at UofL for their PGY-2 year.

a. FCVS and KBML licensure fees are paid for by the GME office.

b. In the fall of the academic year, PGY-1 residents are contacted directly by the GME office and

asked to come to the GME office to complete the paperwork and online application.

i. Licenses for PGY-1 residents are approved at the June Kentucky Board of Medical

Licensure meeting.

ii. License numbers are sent to the GME office and distributed to program coordinators.

iii. License numbers are also available on the KBML website in late June.

License Renewal Process

Full licenses

1. Full licenses expire annually on the last day of February. Residents and fellows who are on Full licenses

must renew their licenses before March 1.

2. Residents should have received notices in the mail to this effect from the KBML and are responsible for

renewing their own licenses.

3. The renewal process is online via the KBML website. The only instances where paper applications will be

accepted are if the applicant answers “yes” to any of the questions on the application. For applications with

“Yes” answers, a paper application will need to be printed and sent to the Board, along with payment and a

written explanation of the “yes” answer.

Training Licenses

1. Training licenses expire annually on June 30.

2. Each program is responsible for coordinating this renewal process for its residents.

3. This renewal process applies to residents with an IP or R license who will be continuing training after June

30.

a. This includes those who are off-cycle and who may only be training for part of next academic

year, even if it is only a few days or weeks. As long as they are under contract at any level above

PGY-2, they must be licensed.

4. All continuing residents on training licenses must renew, with the following exceptions:

a. If a resident has applied for a full license and expects a Temporary or Full license to be issued by

June 30, they should not renew their training license.

b. If a resident has applied to switch from an IP to an R license and this application will be

considered at the June meeting, they do not have to renew their current IP license.

5. The renewal process is completed entirely online via the KBML website. The only instances where paper

applications will be accepted are if the applicant answers “yes” to any of the questions on the application.

For applications with “Yes” answers, a paper application will need to be printed and sent to the Board,

along with payment and a written explanation of the “yes” answer.

6. In cases where a resident is transferring from one UofL program to another, the program that the resident

will be in for the upcoming academic year is responsible for making sure that individual’s license is

renewed.

References & Related Policies

Contact: Kathy Sandman

https://kbml.ky.gov/Pages/index.aspx

Revisions

August 6, 2018 (formatting, definitions)

Resident Policies and Procedures

Section XX.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

MOONLIGHTING AND EXTRA DUTY PAY POLICY & PROCEDURE

Background (Intent)

The Sponsoring Institution must ensure mechanisms are in place to ensure that GME recognized programs follow a

basic set of standards in training and preparing resident and fellow physicians.

Definitions (As used in this Document)

Extra Duty Pay: At the University of Louisville Extra Duty Pay is a specific form of internal moonlighting

whereby a resident or fellow voluntarily assumes additional call or service responsibilities within the

parameters of his or her training program for additional compensation. (It is the only form of moonlighting

that J-1 visa holders are permitted to do).

Moonlighting: Per the ACGME, as voluntary compensated medically related work performed inside (internal) or

outside (external) the institution where the resident is currently training.

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows. Residents in University of Louisville School of Medicine

training programs are classified as students (see item #7 in the Resident Agreement).

Policy/Program Requirements

6. Each sponsored training program at the U of L School of Medicine must have a formal, written policy on

resident Moonlighting that is consistent with the ACGME Institutional, Common Program Requirements,

and this UofL GMEC Policy.

a. The written policy must be provided to all residents and faculty via MedHub.

b. The policy must give guidelines for moonlighting activities of residents, including defining the

hours and rotations when such activities may be permitted, and under what circumstances

permission may be denied for these activities.

c. The policy must include the statements

i. The University does not provide professional liability insurance or any other insurance or

coverage for resident off-duty activities or employment and assumes no liability or

responsibility for such activities or employment. Confirmation of professional liability

insurance for resident off-duty activities or employment will be the responsibility of the

moonlighting employer.

ii. Residents are not to represent themselves to moonlighting employers as being fully

trained in their specialty.

iii. Residents who moonlight are not to present themselves as agents of the University of

Louisville during moonlighting activities. University lab coats, name badges, and

identification cards are not to be worn outside of the resident’s training program

activities.

iv. It is the resident’s responsibility to assure the billing procedures of the moonlighting

employer are conducted in an ethical and legal manner.

7. PGY-1 residents are not permitted to moonlight.

8. Programs must not require residents to participate in moonlighting activities.

9. Resident physicians beyond the PGY-1 year shall be free to use off-duty hours to moonlight so long as the

resident follows program procedures for obtaining the prior written approval of the Department Chair or

Program Director for moonlighting activities.

a. Residents who wish to moonlight must hold either a Regular (R) or Residency Training (RT)

license in Kentucky. Resident Training (RT) licenses permit moonlighting only in locations

authorized and approved by the resident’s Program Director.

b. Institutional Practice (IP) and Fellowship Training (FT) licenses are valid only for duties

associated with the University training program for which these licenses are issued, and do not

cover moonlighting of any type.

10. Program Directors are required to monitor and approve in writing all moonlighting hours and locations for

residents and maintain this information in the resident’s file.

a. This approval must be documented via the Training History in MedHub.

b. Moonlighting activities must not interfere with the resident’s ability to achieve the goals and

objectives of the educational program, or obligations to the University. It must not impair the

effectiveness of the educational program, or cause detriment to the service and reputation of the

hospital to which the resident is assigned.

c. Programs are required to monitor all individual resident moonlighting hours to assure outside

activity does not contribute to excess fatigue or detrimental educational performance.

11. Time spent by residents in Internal and External Moonlighting (as defined in the ACGME Glossary of

Terms) must be counted towards the 80-hour Maximum Weekly Hour Limit. Moonlighting hours must be

entered into MedHub along with standard work hours and documented as Moonlighting Hours, per the

Resident Work Hours Policy & Procedure and the MedHub Use and Responsibilities Policy & Procedure.

12. Programs must obtain approval from the DIO/GME office prior to implementing internal moonlighting or

Extra Duty Pay programs.

Policy/Resident Requirements

1. Residents are required to comply with ACGME, institutional and individual program policies. Residents

found to be in violation of this policy will be subject to disciplinary action as detailed in the University of

Louisville School of Medicine Resident Agreement and the Resident Evaluation, Promotion, and

Termination Policy.

2. Except as described in paragraph 1, residents sponsored on J1 visas are not allowed to moonlight or earn

any income outside of the stipend stipulated in the resident’s house staff contract.

Procedure

1. Programs are required to have the Program specific policy loaded into MedHub.

2. Programs are required to document individual resident approval to moonlight in MedHub.

3. Residents are required to document moonlighting hours in MedHub.

References & Related Policies

ACGME Institutional Requirements, Effective July 1, 2018, Section IV.J.1.: Moonlighting: The Sponsoring

Institution must maintain a policy on moonlighting.

ACGME Common Program Requirements, Effective July 1, 2017 (Section VI Changes)

University of Louisville School of Medicine Resident Work Hours Policy & Procedure

University of Louisville School of Medicine Policies Regarding Foreign Nationals and International Medical

Graduates

University of Louisville School of Medicine MedHub Use and Responsibilities Policy & Procedure

*Program Specific Policy & Procedures for Moonlighting

Approval

Approved by GMEC: 4/17/2000

Revised 3/21/01; 5/21/03; 2/18/04; 11/15/06; 4/20/11; 6/5/13; 1/9/15

Revision approved by GMEC: April 1, 2019

Resident Policies and Procedures

Section XXI.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

MED HUB POLICY FOR RESIDENTS AND FELLOWS

1. Med Hub is a web-based graduate medical education management system. This system helps programs and

institutions to manage schedules, evaluations, work hours, and procedures.

2. All residents and fellows in University of Louisville School of Medicine training programs are required to use the

MedHub Residency Management Suite.

3. Residents and fellows will use the MedHub system to:

a. Log work hours weekly

b. Complete evaluations

c. Log procedures*

d. View block, call, clinic, and conference schedules

4. Residents and fellows will be trained by their Program Coordinators to use the Med Hub system.

*Residents who are required to log their procedures directly with ACGME or their specialty board can provide

summary reports of these entries to their program coordinators instead of logging procedures in Med Hub.

However, the numbers must be entered in Med Hub since our participating hospitals use the Med Hub system to

determine resident credentials.

Resident Policies and Procedures

Section XXII.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

RESIDENT AWAY ROTATIONS GUIDELINES AND PROCESS

As an ACGME (Accreditation Council for Graduate Medical Education) Sponsoring Institution, the University of

Louisville’s School of Medicine has the responsibility to ensure that our graduate medical education residents and

fellows are appropriately supervised and train in safe, effective learning environments.

DEFINITIONS (AS USED IN THIS DOCUMENT)

Away Rotation: a clinical and/or research experience that occurs at a location that is not an established participating

site for the resident’s training program. This is typically an ad-hoc rotation for a single resident, as opposed to a

rotation at an established site used by multiple residents over time.

Elective Rotation: a clinical and/or research experience that meets the needs of one or more residents but is not

required.

International Rotation: an elective, away rotation that occurs outside of the United States. See additional

requirements and processing information.

Participating Site: An organization providing educational experiences or educational assignments/rotations for

residents/fellows. Any hospital, clinic, office or laboratory that serves as a location for resident clinical and/or

research experiences. Sites may have a required and/or an elective rotation.

Program Letter of Agreement (PLA): an official agreement between the training program and each participating

site. The ACGME requires a PLA with any participating site providing a required assignment for the program’s

residents. The PLA identifies the teaching faculty who will supervise and evaluate the resident, specifies the

duration and educational content of the educational experience and states the policies and procedures that govern the

resident education during the assignment.

Resident: Any physician in a University of Louisville (UofL) graduate medical education program recognized by

the GME Office, including interns, residents, and fellows.

Required Rotation: a clinical and/or research experience in which all residents in a program participate as part of

the program curriculum.

AWAY ROTATION GENERAL PRINCIPLES AND GUIDELINES

In the interest of fostering the resident’s self-directed learning, a resident in good standing, and with his/her program

director’s recommendation, may be allowed to take away rotations, not to exceed 30 calendar days collectively,

during the course of his/her training program.

Away rotations at new training sites will be considered if they meet the following criteria:

1. Elective course opportunities desired by the resident that UofL DOES NOT offer, not to exceed 30 calendar

days collectively in the course of the resident’s training program.

2. All other requests will be considered on a case-by-case basis upon the recommendation of the program

director after consideration of the educational rationale and fiscal impact.

PROCESS FOR AWAY ROTATIONS

1. The application packet must be completed and returned to the GME office no less than 60 days in advance

of the rotation begin date. An additional 15 days is required before the start of any international rotation.

a. A completed application includes 3 things:

i. GME Request Form

ii. KMRRRG Request for (Malpractice) Coverage Form

iii. Letter from the Program Director

A letter must accompany the GME and malpractice coverage request forms. The letter

must explain the justification for the rotation and provide the following information:

1. dates of rotation,

2. exact name and address of location,

3. name of attending/supervisory physician who will complete the evaluation

4. specific goals and objectives for the rotation

5. and whether the rotation is an elective rotation or not.

b. Return the completed GME Request Form, the KMRRRG Request for Coverage Form, and the

letter from the program director to:

Kathy Sandman

Graduate Medical Education Office

UofL School of Medicine

323 East Chestnut St

Louisville, KY 40202

2. It is the resident’s responsibility to determine if licensure is required in the state of the rotation and

to obtain appropriate licensure or approval from the applicable state board. NOTE: The medical

licensure process in other states may take longer than 60 days.

3. Please note that some institutions may require additional malpractice coverage beyond what is provided to

residents (250,000 /750,000) or may require participation in a patient compensation fund. If additional

charges are incurred to cover the requested rotation, the resident is responsible for the cost of the additional

coverage if the rotation is an elective or if the resident chooses to complete a required rotation off-site that

could be completed on-site. The program may elect to pay the cost for the resident if they wish.

4. Program directors should confirm that their RRC or certifying board will accept credit given for

observatory rotations.

5. Residents who rotate to out-of-state rotations remain responsible for their medical records. Before

departing for any off-site rotation, residents must be sure to visit all medical records departments to take

care of all incomplete charts and inform them that you will begin an off-site rotation. Doing so can prevent

you from being placed on academic probation or suspended during your absence.

6. When the rotation request is approved, the GME office will sign and return the GME Request Form to the

program office and send the Coverage Request Form to the malpractice carrier. The malpractice carrier

will bill the appropriate responsible party indicated on the GME request form along with confirmation of

coverage.

7. Either a letter of understanding or program letter of agreement (PLA) should be completed and signed by

both institutions. The GME office will provide a PLA template to be completed and signed by the training

site and the UofL program. Should the training institution require their own PLA, the agreement should be

sent to the GME office, where it will be reviewed by University counsel. If any changes are required, those

changes must be implemented before the agreement is signed by the appropriate party.

This letter of understanding or PLA should specify

a. The person or persons responsible for education and supervision

b. Duration of Assignment

c. Responsibilities of the supervising physician to supervise and evaluate the resident

d. Rotation goals and objectives

e. That the University of Louisville will provide stipend, benefits, and malpractice insurance for

the rotation.

LICENSURE AND MALPRACTICE INFORMATION

Rotations which include patient care activity require a license in the state of rotation. NOTE: The medical licensure

process in other states may take longer than 60 days.

Note that some states may require additional malpractice coverage beyond what is provided to residents

($250,000/$750,000), or may require participation in a patient compensation fund. If additional charges are incurred

to cover the requested rotation, the resident is responsible for the cost of the additional coverage if the rotation is an

elective or if the resident chooses to complete a required rotation off-site that could be completed on-site. The

program may elect to pay the cost for the resident if they wish.

ADDITIONAL REQUIREMENTS AND PROCESSING FOR INTERNATIONAL TRAVEL

In addition to the procedures above, any rotation completed outside of the United States requires additional

paperwork and processing. Do not purchase airfare or make lodging arrangements until you have received

authorization from the International Center.

As of January 1, 2020, all SOM faculty, staff, and student international travel applications will need to follow

all guidelines and timelines set forth by the International Travel Office. Failure to follow the process will

result in travel NOT being approved or reimbursed. SOM International travel requests and all required

documentation will need to be managed within the appropriate timelines stated in the process.

Documentation must be submitted as early as 30 days in advance of traveling.

REFERENCES & RELATED POLICIES

ACGME Institutional Requirements, Effective July 1, 2018 (I.B.4.b).(6).)

ACGME Common Program Requirements, Effective July 1, 2017 (Section VI Changes)

University of Louisville Guidelines & Process for Site Additions and Deletions

APPROVAL/REVISIONS

March 19, 2018

October 16, 2018

January 2022 to remove administrative fee

Resident Policies and Procedures

Section XXIII.

RESIDENT PAY DATES AND PAYCHECKS

UNIVERSITY OF LOUISVILLE

SCHOOL OF MEDICINE

Resident Pay Schedule 2023-2024 Resident Stipends

July 29, 2023 January 30, 2024 PG LEVEL ANNUAL MONTHLY

August 30, 2023 February 28, 2024 1 $59,488 $4,957

September 30, 2023 March 31, 2024 2 $61,711 $5,142

October 28, 2023 April 30, 2024 3 $63,703 $5,308

November 30, 2023 May 31, 2024 4 $66,581 $5,548

December 23, 2023 June 30, 2024 5 $69,808 $5,817

6 $72,959 $6,079

7 $75,995 $6,332

8 and up $80,034 $6,669

The following instructions detail how to access your pay stub online. Pay stubs are available only online, no

paper copies will be provided. You will need to verify your identity via UL2FCTR in order to access ULink: see

https://louisville.edu/its/ul2fctr

1.) Navigate to www.ulink.louisville.edu

2.) Click on Workday HR

3.) Click Single Sign On

4.) Verify your identity via UL2FCTR

5.) Find the section marked Menu and click Benefits and Pay

6.) Click View Most Recent Pay

Please contact IT (852-7997), or your departmental Unit Business Manager if you have any problems

accessing your paycheck.

Residents Policies and Procedures

Section XXIV.

University of Louisville School of Medicine

GRADUATE MEDICAL EDUCATION (GME) Policy

Pre-Employment Background Investigation

_____________________________________________________________________________________

I. PURPOSE:

The University of Louisville is required by federal and state law to perform a pre-employment background check on

all new residents and fellows entering its Graduate Medical Education programs. The University of Louisville is

committed to excellence and service to the community in its selection and training of residents and fellows. The

safety and security of our community and the patients served by our graduate medical education training programs

are our highest priority.

II. POLICY

i. Consistent with applicable law, the University of Louisville requires all new hires or re-hires, including

residents and fellows, to submit to a criminal background check. This includes any prior University of

Louisville resident or fellow who has had a break in service and is returning to training on or after this date.

ii. All employment offers, including those resulting from the National Residency Match Program (NRMP),

are conditional upon the successful completion of a background check, as well as primary source

verification of credentials to confirm that the individual possesses the requisite education, training, and

professionalism for the position of graduate medical education physician (resident or fellow). An applicant

who refuses to consent to the processes described above is ineligible for employment as a resident or

fellow.

iii. Applicants to all residency and fellowship programs sponsored or administered by the University of

Louisville will be notified in writing of the requirement for the Background Investigation at the time of

interview, and further, that the conditional offer of employment, including that acquired as a result of the

Match, may be withdrawn in the event the applicant refuses or declines consent to the Background

investigation.

iv. Criminal background checks will be performed through the University of Louisville Human Resources

Department only after the applicant has received an offer of employment.

v. The University of Louisville reserves the right to withdraw an offer of employment from a resident or

fellow if the results of the criminal background check yield information inconsistent with this policy.

vi. Criminal background information released to the University of Louisville will be used only for purposes of

assisting in making hiring or other employment decisions.

III. PROCEDURE

i. Application:

a. Once an applicant has accepted an employment offer, including one which arises from the

National Resident Match Program (NRMP), the Graduate Medical Education Office will enter the

requisite information into the University of Louisville’s human resources management system to

request a criminal background check for the applicant.

b. The applicant will receive an email from the University of Louisville’s approved criminal

background check vendor with instructions for online completion of a criminal background check.

c. The Graduate Medical Education Office will receive electronic confirmation of an applicant’s

completed criminal background check.

d. The hiring process will not move forward until the applicant has completed this online information

to initiate the criminal background check.

ii. Convictions:

a. The existence of a conviction does not automatically disqualify an individual from eligibility for

employment. Relevant considerations may include, but are not limited to: the date, nature and

number of convictions; the relationship the conviction bears to the duties and responsibilities of a

fellow or resident physician; and successful efforts toward rehabilitation.

b. Any decision to reject or accept an applicant with a conviction is solely at the reasonable

discretion of University of Louisville.

c. If the University of Louisville becomes aware that an applicant or current employee has

misrepresented or not been truthful in the screening processes described in this policy, he/she may

be subject to disciplinary action up to and including revocation of the offer or termination.

iii. Results:

a. Confidentiality: Reasonable efforts will be made to ensure that results of criminal background

checks are kept confidential in accordance with applicable law. By virtue of applying for the

residency or fellowship program, the applicant consents to the University of Louisville’s

disclosure of the results to appropriate program personnel at the affiliated site(s) at which the

resident or fellow will perform his or her training as necessary to assist in its review.

b. Access to Results: The University of Louisville Human Resources Department reviews those

criminal background checks that yield findings. If adverse information deemed to be relevant to

the applicant’s suitability for employment as a resident or fellow is contained in the criminal

background check, the University of Louisville Human Resources Department and/or its vendor

will notify the applicant in writing.

c. Information Available through Background Checks: The criminal background check will include a

record of all arrests and convictions.

d. Ability of Applicant to Review Information: An applicant whose criminal background check

yields findings will be provided a copy by the University of Louisville Human Resources

Department or its approved vendor.

e. Right to Respond to Adverse Report: The applicant may submit additional written information,

including an explanation of the occurrence(s), to the University of Louisville Human Resources

Department for consideration in the employment decision. Such information may be shared with

the appropriate representatives of the Office of Graduate Medical Education for consideration.

f. If the conditional offer of employment is to be withdrawn, the Residency Program/Graduate

Medical Education Office must request a Match waiver from the National Residency Match

Program (NRMP) prior to rescinding the offer. For all other residents and fellows, GME shall

advise the individual in writing that its conditional offer of employment is rescinded.

g. If the resident or fellow applicant feels that a National Residency Match Program (NRMP)

violation has occurred as a result of the revocation the applicant may contact the National

Residency Match Program (NRMP) or other applicable Match program.

h. Right to Change and/or Terminate Policy: Reasonable efforts will be made to keep employees

informed of any changes in the policy. However, the University of Louisville reserves the right, in

its sole discretion, to amend, replace, and/or terminate this policy at any time.

Approved by GMEC: November 17, 2021

Residents Policies and Procedures

Section XXV.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

PROGRAM CLOSURE (WITHDRAWAL) POLICY & PROCEDURE

BACKGROUND (INTENT)

The Accreditation Council for Graduate Medical Education requires the University of Louisville, as a Sponsoring

Institution, to establish a Graduate Medical Education Committee (GMEC). GMEC responsibilities include

oversight of all processes related to reductions and closures of individual ACGME-accredited programs, major

participating sites, and the Sponsoring Institution.

DEFINITIONS (AS USED IN THIS DOCUMENT)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows.

Withdrawal of Accreditation: Accreditation may be withdrawn when a Review Committee (RC, RRC) determines

that a program has failed to demonstrate substantial compliance with the applicable requirements. A

program must undergo a site visit before a Review Committee may withdraw its accreditation.

Withdrawal of Accreditation under Special Circumstances: Regardless of a program’s accreditation status, the

Review Committee may withdraw the accreditation of a program based on clear evidence of non -

substantial compliance with accreditation standards, such as:

(1) A catastrophic loss of resources, including faculty members, facilities, or funding; or,

(2) Egregious non - compliance with accreditation requirements.

Administrative Withdrawal: A program may be deemed to have withdrawn from the voluntary process of

accreditation if it does not comply with the following actions and procedures:

(1) Undergo a site visit and Sponsoring Institution or program review;

(2) Follow directives associated with an accreditation action;

(3) Supply the Review Committee with requested information (e.g., a progress report, operative data,

Resident or Faculty Survey, or other information);

(4) Maintain current data in the Accreditation Data System (ADS);

(5) Undergo a site visit and review while on Administrative Probation; or ,

(6) Matriculate residents for six or more consecutive years.

Voluntary Withdrawal of Accreditation: A program may request Voluntary Withdrawal of Accreditation.

POLICY

1. The GMEC has delegated review and approval of complement changes (reductions of a program) and

Changes in Participating Sites to the Accreditation Subcommittee. These are addressed in separate process

documents.

2. The GMEC will review any request for a residency closure or withdrawal.

3. Requests for program withdrawal must be submitted to the GME Office in writing.

a. The request must be signed by the Program Director, Department Chair, and, if applicable, the

Division Director.

b. The request must include a proposed closure date that should coincide with the end of an academic

year.

c. The request must state whether residents are currently enrolled, and if so, describe a plan for

placement.

4. A program that has requested Voluntary Withdrawal of Accreditation or has had its Accreditation

Withdrawn:

a. may not accept new residents and/or fellows;

b. may not request “reversal” of the action after submitting the request (regardless of the proposed

effective date);

c. may seek re - accreditation after a period of 12 months following the effective date of the

Voluntary Withdrawal; and, (d) through its Sponsoring Institution, is responsible for placement of

its current residents in other ACGME-accredited programs.

5. The effective date of the withdrawal shall be determined by the Review Committee.

Note: If a program reapplies for accreditation within two years of the effective date of withdrawal, the accreditation

history of the previous accreditation action shall be included as part of the file. The program shall include a

statement addressing each previous citation with the new application. A site visit must be conducted for all re -

applications after withdrawal of accreditation. This is addressed under separate policy & procedure.

PROCEDURE

13. In the event that a training program must be closed, the Program Director must notify the residents enrolled

in the program as soon as possible and copy the DIO on this correspondence.

14. In the event of program closure for reasons other than loss of accreditation, residents already in the

program will be permitted to complete their training, or may elect to transfer to another program. Residents

who wish to transfer will be assisted by the institution in enrolling in other programs.

15. In the event accreditation is withdrawn from a training program, residents already in the program will be

permitted to continue in the program until the effective date of the withdrawal of accreditation. The

institution will assist residents in enrolling in other ACGME-accredited programs in order to continue their

training.

16. This policy applies to all graduate medical education training programs sponsored by the University of

Louisville School of Medicine GME Office.

REFERENCES & RELATED POLICIES

ACGME Institutional Requirements, Effective July 1, 2018, Section I.B.4.a).(5): GMEC Responsibilities must

include oversight of all processes related to reductions and closures of individual ACGME-accredited programs,

major participating sites, and the Sponsoring Institution; and, (Core)

ACGME Institutional Requirements, Effective July 1, 2018, Section I.B.4.b.(11): GMEC Responsibilities must

include review and approval of voluntary withdrawal of ACGME program accreditation; (Core)

ACGME Institutional Requirements, Effective July 1, 2018, Section IV.N: Closures and Reductions: The

Sponsoring Institution must maintain a policy that addresses GMEC oversight of reductions in size or closure of

each of its ACGME-accredited programs, or closure of the Sponsoring Institution. (Core)

ACGME Policies and Procedures, effective 2/3/2018, Subject 18.00 Accreditation and Recognition Actions

APPROVAL

Approved by GMEC: October 16, 2002

Revision approved by GMEC: April 1, 2019

Residents Policy and Procedure

Section XXVI.

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

RESTRICTIVE COVENANTS POLICY & PROCEDURE

BACKGROUND (INTENT)

As an ACGME Sponsoring Institution, the University of Louisville’s responsibility is to provide oversight of

resident agreements of appointment/contracts.

DEFINITIONS (AS USED IN THIS DOCUMENT)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows. Residents in University of Louisville School of Medicine

residency programs are classified as students (see item #7 in the Resident Agreement).

Restrictive Covenant: A non-competition guarantee in which an employee agrees not to enter into or start a similar

profession or trade in competition against the employer.

POLICY

1. The ACGME specifically prohibits the use of Restrictive Covenants in trainee agreements.

2. Neither the University of Louisville School of Medicine nor its graduate medical education programs may

require residents or fellows to sign a non-competition guarantee or restrictive covenant.

3. Residents or fellows are free to compete for physician and/or academic positions in any geographic area

upon completion of their training program.

PROCEDURE

1. Any resident asked to sign a restrictive covenant or non-competition guarantee should report such request

to the Designated Institutional Official.

REFERENCES & RELATED POLICIES

ACGME Institutional Requirements, Effective July 1, 2018, Section IV.L: Non-competition: The Sponsoring

Institution must maintain a policy which states that neither the Sponsoring Institution nor any of its ACGME-

accredited programs will require a resident/fellow to sign a non-competition guarantee or restrictive covenant.

(Core)

APPROVAL

Undated

Revised March 27, 2019; Approved by GMEC April 1, 2019

Residents Policy and Procedure

Section XXVII.

UNIVERSITY OF LOUISVILLE

OFFICE OF THE PRESIDENT

POLICY AND PROCEDURES ON SEXUAL HARASSMENT

POLICY STATEMENT

The University of Louisville (University) is committed to fostering an atmosphere free from Sexual Misconduct.

The University will take prompt and appropriate action to eliminate Sexual Misconduct, prevent recurrence, and

remedy any effects on the Complainant or those involved in the complaint process. If, in the process of the

investigation, the University determines that the alleged conduct does not fall within the scope of this or other

University policies, both the Complainant and the Respondent will be notified in writing.

Any University employee who is the victim of or been a witness to Sexual Misconduct in the workplace should

promptly notify Employee Relations and Compliance Office at 502-852-6258 or emrelate@louisville.edu

. Prompt

notification to one or more of the individuals identified in the policy under “Reporting a Sexual Misconduct

Complaint” is also sufficient. In an emergency, individuals should contact University Police at 502-852-6111 or call

911.

When the University finds the Respondent has violated this policy, disciplinary or other administrative action will be

issued. A policy violation is not required in order to provide certain Supportive Measures for the Complainant

reporting the concern. Possible Supportive Measures include but are not limited to the following: mutual "no contact

orders," changes to academic, living or working situations as appropriate, counseling services, security escort

services, medical services, academic support services, and notification of the right to file a complaint with local law

enforcement. The Title IX Coordinator, Deputy Title IX Coordinators, or their designee will provide information

regarding this policy, complaint resolution procedures, and offer options for addressing a complaint.

The complete university policy may be found at https://louisville.edu/policies/policies-and-

procedures/pageholder/pol-title-ix-employee-sexual-misconduct

Resident Policies and Procedures

Section XXVIII.

UNIVERSITY OF LOUISVILLE SCHOOL OF MEDICINE

Student Mistreatment Policy

(Appropriate Learner-Educator Relationships and Behavior Policy)

The University of Louisville School of Medicine is committed to ensuring an environment that is respectful of

diversity of opinion, race, gender, religion, sexual orientation, age, disability and socioeconomic status. Mutual

respect and collegiality among faculty, residents, students and staff is essential to maintaining an environment

conducive to learning. All members of the University community are expected to adhere to the Code of Conduct.

Student Mistreatment is defined as a behavior that shows disrespect for the dignity of others and unreasonably

interferes with the learning process. It includes harassment, discrimination, or physical threats.

Specific examples of mistreatment can include, but are not limited to, being:

• Subjected to offensive remarks or names

• Pressured into performing personal services

• Intentionally neglected or left out of conversations

• Belittled or humiliated

Any abuse or misconduct of a sexual nature will be reported through the Title IX process as outlined by the

University of Louisville.

Students may report mistreatment using any of the following avenues:

• Directly report concerns about mistreatment confidentially to the Associate Dean for Student Affairs, the

Assistant Dean for Student Affairs, the Vice Dean for Undergraduate Medical Education, the Assistant

Dean for Clinical Skills or the Health Science Counseling Coordinator.

• Complete this

online form with the option of anonymously reporting a mistreatment:

• Document the mistreatment on course evaluations.

All reports submitted through these mechanisms will be received by the Associate Dean for Student Affairs and will

be reviewed with the Vice Dean for Undergraduate Medical Education on a monthly basis. Trends will be

monitored. The individual mistreatment incidents as well as trends will be brought to the attention of the Vice Dean

for Faculty Affairs (if faculty involved) or Associate Dean for GME (if resident involved), as well as the appropriate

Chair or Program Director, or appropriate administrator at the clinical site. The responsible supervisor will have ten

business days to initiate a response and communicate this to the Associate Dean for Student Affairs.

Incidents submitted through this form may be made anonymously, however, UofL is limited in its ability to

investigate and respond to anonymous reports. The preference is for all reports to include contact information such

that follow up can occur.

Retaliation against students reporting mistreatment is regarded as a form of mistreatment and will not be tolerated.

Accusations that retaliation has occurred will be handled in the same manner as accusations concerning other forms

of mistreatments.

Resident Policies and Procedures

Section XXIX.

UNIVERSITY OF LOUISVILLE GRADUATE MEDICAL EDUCATION

RESIDENT SELECTION POLICY & PROCEDURE

BACKGROUND (INTENT)

The sponsored residency training programs of the University of Louisville School of Medicine exist for the purpose

of training the highest quality physician possible in each program’s respective discipline. The following is the

official policy for the selection of candidates for training. This policy is consistent with the Accreditation Council on

Graduate Medical Education (ACGME) Institutional Requirements and the Commonwealth of Kentucky Medical

and Osteopathic Practice Act Regulations and Statutes. Program directors and coordinators should also be familiar

with the “Medical Licensure Policy for Residents” published in the Resident Policies and Procedures manual.

Program directors and coordinators are strongly encouraged to call the Office of Graduate Medical Education if

questions, problems or uncertainty arise.

DEFINITIONS (AS USED IN THIS DOCUMENT)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows. Note: The term “resident” in this document refers to both specialty

residents and subspecialty fellows.

POLICY

1. Each program must develop standards for resident qualifications and eligibility and the selection process in

accordance with the program’s accreditation requirements, Board Certification requirements, and institutional

policy.

2. Resident Eligibility Applicants with one of the following qualifications are eligible for appointment to accredited

residency programs at the University of Louisville School of Medicine.

a. Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on

Medical Education (LCME).

b. Graduates of medical schools in the United States and Canada accredited by the American Osteopathic

Association (AOA).

c. Graduates of medical schools outside of the United States and Canada who have current valid certificates

from the Educational Commission for Foreign Medical Graduates (ECFMG). In addition, as of the 2009-

2010 academic year, schools located outside the U.S. and Canada must:

i. Be officially recognized in good standing in the country where they are located

ii. Be registered as a medical school, college, or university in the International Medical Education

Directory

iii. Require that all courses must be completed by physical on-site attendance in the country in

which the school is chartered.

iv. Possess a basic course of clinical and classroom medical instruction that is 1. not less than 32

months in length; and 2. under the educational institution’s direct authority.

d. Graduates from accredited dental schools who are enrolled in oral-maxillofacial surgery and general

practice dentistry (GPR) programs. These programs are accredited by the Council on Dental Accreditation

of the American Dental Association but are under the general auspices of the University of Louisville

School of Medicine Graduate Medical Education Programs. Candidates must obtain dental licensure

through the Kentucky Board of Dentistry.

e. ACGME Residency programs must require all prerequisite post-graduate clinical education required for

initial entry or transfer be completed in ACGME-accredited residency programs, AOA-approved residency

programs, Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family

Physicians of Canada (CFPC)-accredited residency programs located in Canada, or in residency programs

with ACGME International (ACGME-I) Advanced Specialty Accreditation.

i. A physician who has completed a residency program that was not accredited by ACGME, AOA,

RCPSC, CFPC, or ACGME-I (with Advanced Specialty Accreditation) may enter an ACGME-

accredited residency program in the same specialty at the PGY-1 level and, at the discretion of the

program director of the ACGME-accredited program and with approval by the GMEC’s

Accreditation Subcommittee may be advanced to the PGY-2 level based on ACGME Milestones

evaluations at the ACGME-accredited program. This provision applies only to entry into residency

in those specialties for which an initial clinical year is not required for entry.

f. ACGME Fellowship programs must note if the Review Committee (RC) allows exceptions under

Common Program Requirements section III.A

i.If the RC allows exceptions, the program must further note if the program will consider

exceptions.

ii.If the program is considering an exceptionally qualify applicant who does not satisfy the

eligibility requirements listed in ACGME III.A.1, programs must provide evaluation by the

program director and fellowship selection committee of the applicant’s suitability to enter the

program, based on prior training and review of the summative evaluations of training in the core

specialty for review and approval by the GMEC’s Accreditation Subcommittee PRIOR to any

offer of a position. If relevant, material provided to the Accreditation Subcommittee must include

Educational Commission for Foreign Medical Graduates (ECFMG) certification information.

3. Non-US Citizens/Foreign Nationals

a. Applicants who are not citizens of the United States must possess or be eligible for one of the following:

•J1 Clinical Visa

•Valid Employment Authorization Document

•Valid Permanent Resident Card

b. The following are not accepted for residency or fellowship training:

•J1 Research Visa

•J2 Dependent Visa

•H1B Visa

c. Individual programs may limit the amount of time they will hold a position open for applicants to obtain

appropriate immigration status.

d. More information is available Foreign National and International Medical Graduates Policy and

Procedure.

4. All resident selection must be made without unlawful discrimination in terms of age, color, disability status,

national origin, race, religion or sex, in keeping with University of Louisville standards as an Affirmative

Action/Equal Opportunity employer.

5. The enrollment of non-eligible residents may be cause for withdrawal of accreditation of the involved

program and/or the sponsoring institution.

PROCEDURE & PROGRAM REQUIREMENTS ON RESIDENT SELECTION

1. Recruitment processes are to be determined at the program level in accordance with ACGME and institutional

policies.

2. Programs should select from among eligible applicants on the basis of their preparedness and ability to benefit

from the program to which they are appointed. Aptitude, academic credentials, personal characteristics, and ability

to communicate should be considered in the selection. Personal interviews prior to selection are strongly

encouraged.

3. In selecting from among qualified applicants for first-year positions, sponsored programs must participate in the

National Resident Matching Program (NRMP) or other national matching program when it is available.

4. In selecting from among eligible applicants for positions other than the first-year positions, programs should

select the most qualified candidates as listed in 2.a. above. Appointment to PGY2 (and above) positions is

contingent upon candidates being issued a valid Kentucky medical licenses prior to the beginning of the training

year. More information is available via the Medical Licensure Policy for Residents.

5. All positions offered or matched are contingent upon successful completion and passing of a local and national

Criminal Background Check (CBC). See the CBC Policy for additional information.

REFERENCES & RELATED POLICIES

UofL GME Foreign National and International Medical Graduates Policy and Procedure.

UofL GME Guidelines on Postgraduate Level Designations

UofL GME Medical Licensure Policy for Residents

UofL GME CBC Policy

ACGME Institutional Requirements, Effective July 1, 2021 (Section IV.A)

ACGME Common Program Requirements (Residency, Fellowship, One-Year Fellowship), Effective July 1, 2020

APPROVAL

Revision Approved by GMEC: 2/16/2011, 6/16/2021

Resident Policies and Procedures

Section XXX

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

POLICY AND PROCEDURE FOR RESIDENT SUPERVISION

Background (Intent)

The specialty education of physicians to practice independently is experiential, and necessarily occurs within the

context of the health care delivery system. Developing the skills, knowledge, and attitudes leading to proficiency in

all the domains of clinical competency requires the resident physician to assume personal responsibility for the care

of individual patients. For the resident, the essential learning activity is interaction with patients under the guidance

and supervision of faculty members who give value, context, and meaning to those interactions. As residents gain

experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to

exercise those skills with greater independence. This concept--graded and progressive responsibility-is one of the

core tenets of American graduate medical education. Supervision in the setting of graduate medical education has

the goals of assuring the provision of safe and effective care to the individual patient; assuring each resident’s

development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and

establishing a foundation for continued professional growth.

The Office of Graduate Medical Education of the University of Louisville, School of Medicine is, in turn, required

by the Accreditation Council of Graduate Medical Education (ACGME) to ensure that the individual training

program’s policy, and practice, are in compliance with both the RRC and ACGME requirements. Failure to adhere

to these requirements may result in loss of accreditation of the training program and/or institution.

Definitions (As used in this Document)

Resident: Any physician in a University of Louisville graduate medical education program recognized by the GME

Office, including interns, residents, and fellows. Note: The term “resident” in this document refers to both specialty

residents and subspecialty fellows.

Policy & Program Requirements

1. Each training program (residency and fellowship) must develop a program specific policy addressing

resident training and supervision that is consistent with the ACGME Institutional, Common Program

Requirements, and this UofL GMEC Policy.

2. It is the responsibility of the program directors of resident training programs to know, and to adhere to, the

training program’s specific RRC requirements for resident supervision.

3. Residency programs are responsible for creating a periodic call schedule, which clearly identifies the

primary on-call resident and the appropriate chain of supervision, including the name of the supervisory

attending physician. The schedule should contain pertinent information (telephone number, beeper/pager

number, etc.) necessary to quickly and efficiently contact the members in the chain of command. Copies of

the call schedule should be available to the residents and the key personnel at the training sites (clinics,

hospital operators, etc.). It is the responsibility of the residency program to keep the call schedule current

and accurate.

Procedure

17. Programs are required to have the Program specific policy loaded into MedHub.

18. Programs are required to set guidelines for circumstances and events in which residents must communicate

with appropriate supervising faculty members, such as the transfer of a patient to an intensive care unit, or

end-of-life decisions. (See guideline in the GME Policy & Procedure for Transitions of Care)

19. Residents must be appropriately supervised by teaching staff at all times and in such a way that the

individual resident is allowed to assume progressively increasing responsibilities according to their level of

education, ability, and experience. The teaching staff of the respective program is responsible for

determining the level of responsibility accorded each resident. (See GME Policy & Procedure for Resident

Evaluation, Remediation, Promotion, and Dismissal)

a. Faculty supervision assignments should be of sufficient duration to assess the knowledge and

skills of each resident and delegate to him/her the appropriate level of patient care authority and

responsibility.

b. Each resident must know the limits of his/her scope of authority, and the circumstances under

which he/she is permitted to act with conditional independence.

c. In particular, PGY-1 residents should be supervised either directly or indirectly with direct

supervision immediately available. [Each Review Committee will describe the achieved

competencies under which PGY-1 residents’ progress to be supervised indirectly, with direct

supervision available.]

20. Senior residents or fellows should serve in a supervisory role of junior residents in recognition of their

progress toward independence, based on the needs of each patient and the skills of the individual resident

or fellow. However, at no time should the resident not have access to a supervisory attending.

21. To ensure oversight of resident supervision and graded authority and responsibility, the program must use

the following classification of supervision from the ACGME Common Program Requirement effective July

1, 2011:

a. Direct Supervision – the supervising physician is physically present with the resident and patient.

b. Indirect Supervision with direct supervision immediately available – the supervising physician is

physically within the hospital or other site of patient care and is immediately available to provide

Direct Supervision.

c. Indirect Supervision with direct supervision available – the supervising physician is not physically

present within the hospital or other site of patient care, but is immediately available by means of

telephonic and/or electronic modalities, and is available to provide Direct Supervision.

d. Oversight – The supervising physician is available to provide review of procedures/encounters

with feedback provided after care is delivered.

22. Residents should be informed that if they are at any time concerned about the availability or level of

supervision, they should contact their residency program director, the departmental chairperson, the

Associate Dean for Educational and Work Environment, the Resident Ombuds, or the office of Graduate

Medical Education of the University of Louisville School of Medicine.

23. Compliance with the RRC’s requirements for resident supervision must be attested to in the Annual

Program Evaluation (APE) report submitted to the GME Office.

24. All programs must upload a copy of their written policy on Resident Supervision into MedHub.

References & Related Policies

ACGME Institutional Requirements, Effective July 1, 2015

ACGME Common Program Requirements, Effective July 1, 2017 (Section VI Changes)

GME Policy & Procedure for Transitions of Care

GME Policy & Procedure for Resident Evaluation, Remediation, Promotion, and Dismissal

Approval

December 2001, Revisions approved by GMEC: March 16, 2011, Revisions approved by GMEC: May 21, 2014,

Revised: September 18, 2017; Revisions approved by GMEC: February 2018. Effective July 1, 2017

Resident Policies and Procedures

Section XXXI

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

TRAINING SITES 2023-2024

502 DIRECT PRIMARY CARE

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EALTH

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AMERICAN MEDICAL

RESPONSE - LOUISVILLE

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ROSS

LOUISVILLE REGION

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NCHORAGE

IDDLETOWN

FIRE AND EMS

ANESTHESIOLOGY ASSOCIATES

SSOCIATES IN

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ASSOCIATES IN DERMATOLOGY

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APTIST

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BAPTIST HEALTH DEACONESS -

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(FORM. FLOYD MEMORIAL)

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NCMG

ROWNSBORO

NCMG

ENETICS

ENTER

NCMG - NORTON CHILDREN'S

BEHAVIORAL & MENTAL

HEALTH

NCMG

ORTON

HILDREN

DEVELOPMENT CENTER

NCMG

ORTON

HILDREN

ENDOCRINOLOGY

NCMG

ORTON

HILDREN

HEMATOLOGY & ONCOLOGY

NCMG

ORTON

HILDREN

MEDICAL GROUP -

STONESTREET

NCMG

ORTON

HILDREN

NEONATOLOGY SPECIALISTS

NCMG

ORTON

HILDREN

NEUROLOGY

NCMG

ORTON

HILDREN

PEDIATRIC PROTECTION SPEC

NCMG

ORTON

HILDREN

AUTISM CENTER

NCMG

OVAK

ENTER FOR

CHILDREN'S HEALTH

NCMG - PHYSICAL MEDICINE

AND REHABILITATION

NCMG

ROLOGY

EUROLOGY

ULPOC

ORK

RESBYTERIAN

THE UNIVERSITY HOSPITAL

EXT

TEP

ENTAL

EALTH

NHC

ATIONAL

HEALTHCARE CORPORATION

ORTHERN

IGHT

ASTERN

MAINE MEDICAL CENTER

ORTON

210

RAY

LDG

(PRIVATE PRACTICE)

NORTON AUDUBON HOSPITAL

ORTON

ROWNSBORO

HOSPITAL

NORTON CANCER INSTITUTE -

DOWNTOWN

ORTON

HILDREN

HOSPITAL

ORTON

HILDREN

MEDICAL CENTER -

BROWNSBORO

NORTON CHILDREN'S

MEDICAL GROUP

ORTON

CMA

UDUBON

ORTON

CMA

ARRET

ORTON

CMA

ROWNSBORO

ORTON

CMA

ULLITT

COUNTY

ORTON

CMA

IXIE

ORTON

CMA

INCASTLE

ORTON

CMA

HURSTBOURNE

ORTON

CMA

AKEVIEW

ORTON

CMA

ALLARD

CREEK

ORTON

CMA

WASHINGTON

NORTON CMA - PRESTON

ORTON

CMA

HELBYVILLE

ORTON

CMA

SHEPHERDSVILLE

ORTON

EALTHCARE

PAVILION

ORTON

OSPITAL

ORTON

MMEDIATE

ARE

CENTER - HIGHLANDS

ORTON

EATHERMAN

PINE

CENTER

ORTON

EDICAL

LAZA

BROWNSBORO CROSSING

ORTON

EDICAL

LAZA

MATTHEWS

ORTON

EUROLOGY

SERVICES

NORTON NEUROSCIENCE

INSTITUTE SPORTS

NEUROLOGY CEN

NORTON ORTHOPEDIC

INSTITUTE - ANGIE'S WAY

ORTON

RTHOPEDIC

INSTITUTE - DUTCHMAN

ORTON

LEEP

EDICINE

SPECIALISTS

ORTON

ROGYNECOLOGY

CENTER

NORTON WOMEN'S &

CHILDREN'S HOSPITAL

OBGYN

ACB

OBGYN

ULPOC

FFICE OF THE

COMMONWEALTH'S

ATTORNEY

LDHAM

OUNTY

EMS

LDHAM

OUNTY

EDIATRICS

RTHOPAEDICS

ULPOC

ORTHOPEDIC SPECIALISTS

THER

WENSBORO

ERMATOLOGY

ASSOCIATES

WENSBORO

EALTH

BRECKENRIDGE MEDICAL

BUILDING

WENSBORO

EALTH

OUTPATIENT IMAGING - THE

PRINGS

WENSBORO

EALTH

REGIONAL HOSPITAL

ARK

UVALLE

OMMUNITY

HEALTH CENTER

PARSLEY/WALDMAN HAIR

CENTER

EDIATRIC

NESTHESIA

ASSOCIATES, PSC

PEDIATRIC RHEUMATOLOGY

@ ULPOC

EDIATRICS OF

ULLITT

COUNTY

PGXL

ABORATORIES

HYSICIAN

EDICAL

ENTER

(PMC) OUTPATIENT SURGERY

PHYSICIAN'S MEDICAL

CENTER

HYSICIANS

ENTER

(OWENSBORO)

REMIER

URGERY

ENTER

RIVATE

RACTICE

PROSPECT INTERNAL

MEDICINE

SYCHIATRY

ULPOC

RESEARCH – NON- VA

SUPPORTED

ESEARCH

ULH

UPPORTED

RESEARCH - VA SUPPORTED

HEUMATOLOGY

ASSOCIATES., PLLC D/B/A

ARTHRITIS ASS

ICHARD

ILLER

RAL

HEALTH CLINIC

IVER

IDGE

URGICAL

SUITES, LLC

OND

CHRADER

LINIC

ACRED

EART

OME

VILLAGE

ELLERSBURG

NTERNAL

MEDICINE & PEDIATRICS

EVEN

OUNTIES

ERVICES

ADULT DOWNTOWN

EVEN

OUNTIES

ERVICES

ATKINSON ELEMENTARY

EVEN

OUNTIES

ERVICES

CHAMPIONS TRACE

EVEN

OUNTIES

ERVICES

EAST BROADWAY

HEA

RTHOPEDIC

ROUP

OUTH

ENTRAL

ENTUCKY

ORTHOPAEDICS

OUTH

OUISVILLE

PEDIATRICS

OUTHERN

NDIANA

EHAB

HOSPITAL

SOUTHERN KENTUCKY

NEPHROLOGY ASSOCIATES

PRINGS

EDICAL

ENTER

OSEPH

OSPITAL

(LEXINGTON)

INCENT

OSPITALS AND

HEALTH CARE CENTER

UBURBAN

XCIMER

ASER

CENTER

URGCENTER OF

OUISVILLE

TAPP

OUTH

ARK

TAPP

ESTPORT

TATE INSTITUTE FOR FEMALE

PELVIC HEALTH

ELLURIDE

EDICAL

ENTER

TEMPLE UNIVERSITY

HOSPITAL

ROOK

UPONT

THE BROOK - LAGRANGE

ROAD

ENTER FOR

COURAGEOUS KIDS

AMSON

OMMUNITY

HOSPITAL

AMSON

AMILY

EDICINE

CENTER

TJ SAMSON HEALTH

PARTNERS

AMSON

EALTH

AVILION

OTAL

EALTHCARE FOR

WOMEN

REYTON

OWERS

UK HEALTHCARE TURFLAND

THLETICS

THLETIC

TRAINING ROOM

UL SPORTS MED @ FRAZIER

ULP

ROGYNECOLOGY AT

M&E

ULP

ROGYNECOLOGY AT

SPRINGS MEDICAL CENTER

ULP

ROGYNECOLOGY AT

ULPOC

ULP ORTHOPAEDICS: GREY

STREET

ULP

RTHOPAEDICS

RESGE

WAY

UNIVERSITY

DERMATOPATHOLOGY, PLLC

NIVERSITY

IDNEY

ENTER

3RD STREET

NIVERSITY

IDNEY

ENTER

BLUEGRASS

NIVERSITY OF

ALIFORNIA

SAN FRANCISCO

NIVERSITY OF

HICAGO

NIVERSITY OF

INCINNATI

BARRETT CANCER CENTER

NIVERSITY OF

INCINNATI

MEDICAL CENTER

NIVERSITY OF

ENTUCKY

NIVERSITY OF

ENTUCKY

CHANDLER MEDICAL CENTER

NIVERSITY OF

OUISVILLE

UNIVERSITY OF LOUISVILLE

KIDNEY DISEASE BUILDING

NIVERSITY OF

ICHIGAN

HEALTH SYSTEM

UNIVERSITY OF TEXAS MD

ANDERSON CANCER CENTER

NIVERSITY OF

ORONTO

UNIVERSITY OF WASHINGTON

MEDICAL CENTER

AMILY

EDICINE

MECH

UOFL HEALTH - ABRAHAM

FLEXNER OUTPATIENT CARE

CENT

EALTH

ROWN

CANCER CENTER

(DOWNTOWN)

EALTH

HESTNUT

HEALTH CARE OUTPATIENT

CTR

UOFL HEALTH - FRAZIER

REHABILITATION INSTITUTE

EALTH

ACKSON

AMB CARE BUILD

UOFL HEALTH - JEWISH

HOSPITAL

EALTH

ARY

LIZABETH

OSPITAL

EALTH

ARY

ELIZABETH HOSPITAL PLAZA I

EALTH

EDICAL

CENTER EAST

EALTH

EDICAL

CENTER EAST

EALTH

EDICAL

CENTER EAST (ULP)

UOFL HEALTH - MEDICAL

CENTER NORTHEAST

EALTH

EDICAL

CENTER NORTHEAST (ULP)

UOFL HEALTH - MEDICAL

CENTER SOUTH

EALTH

EDICAL

CENTER SOUTHWEST

UOFL HEALTH - PEACE

HOSPITAL

EALTH

EACE

HOSPITAL GERIATRIC UNIT AT

FRA

EALTH

HELBYVILLE

HOSPITAL

EALTH

NIVERSITY

LOUISVILLE HOSPITAL

EALTH

-F

RAZIER

REHAB INSTITUTE-SPORTS

MED CTR

EDIATRICS

HILD

YOUTH CLINIC

UOFL PEDIATRICS - EASTERN

PARKWAY @ SSKCC

SPIRITUS

ROOKLAWN

ANDERBILT

NIVERSITY

MEDICAL CENTER

ETERANS

DMINISTRATION

HOSPITAL: INDIANAPOLIS

ETERANS

DMINISTRATION

HOSPITAL: LEXINGTON

ETERANS

DMINISTRATION

MEDICAL CENTER (ROBLEY

REX)

ASHINGTON

NIVERSITY

LOUIS)

WOMEN'S FIRST [IN BAPTIST

MEDICAL PAVILION]

502 Direct Primary Care

Adanta Behavioral Health

Services - Columbia Clinic

Air Methods Kentucky

American Academy of

Pediatrics (AAP) -

Washington,

American Institute for

Radiologic Pathology

American Medical Response -

Louisville

American Red Cross -

Louisville Region

American Red Cross - St.

Louis

Anchorage Middletown Fire

and EMS

Anesthesiology Associates

Associates in Dermatology -

Audubon

Associates in Dermatology -

East End

Associates in

Obstetrics/Gynecology [In

Baptist Me

AXIS Forensic Toxicology

Laboratory

B.C. Cancer Agency

Baptist Eastpoint Surgery

Center

Baptist Health Deaconess -

Madisonville

Baptist Health Floyd (form.

Floyd Memorial)

Baptist Health Hardin (form.

Hardin Memorial Hospital

Baptist Health Hospital

LaGrange

Baptist Health Louisville

Baptist Health Medical Group

FM - Floyds Knobs

Baptist Health Medical Group

IM & PEDS - Crestwood

Baptist Health Medical Group

IM & PEDS - Radcliff

Baptist Health Medical Group

PC - LaGrange

Baptist Health Medical

Group: Purchase ENT

Baxter I

Baxter II

BellaPelle Dermatology &

Cosmetic Laser Center

Bennett & Bloom Eye Center

Brigham and Women's

Hospital

Brownsboro Dermatology

Bullitt County EMS

Cabinet for Health & Family

Services - Frankfort

Camp Hendon

Cassis Dermatology &

Aesthetics Center

CCSHCN - Bowling Green

CCSHCN - Elizabethtown

CCSHCN Clinic - Louisville

CCSHCN Clinic - Owensboro

CCSHCN Clinic - Paducah

Centerstone @ Maupin

Elementary School

Centerstone @ Wheatley

Elementary

Centerstone Acute Services

Centerstone Addiction

Recovery Center (JADAC)

Centerstone Mental Health

Central Kentucky Foot

Specialists/Mark Risen

Central State Hospital

Child Abuse Multi-

Disciplinary Team

Children's Advocacy Center of

the Bluegrass

Children's Foundation

Building

Children's Orthopedics of

Louisville

Cincinnati Children's Hospital

Clark Memorial Hospital

Commonwealth Foot & Ankle

Center

Cox Health Medical Center

CPA Lab

Crabtree Dermatology &

Aesthetics

Daviess County Health

Department

DCBS Jeff Co CPS

Department of Urology

Academic Office

Diagnostic Imaging Alliance

Dupont Surgery Center, ARC

Eastern Virginia Medical

School

Ellis & Badehausen

Orthopedics - Dixie

Ellis & Badehausen

Orthopedics - East Point

Emergency Medical

Associates/MetroSafe

EMW Women's Surgical

Center

ENT Bowling Green

Episcopal Church Home

Eye Care of Southern KY -

Ward & Coomer

Family Medical Center of

Hart County

Family & Children's Place

Child Advocacy Center

Family & Children's Place

Mental Health

Family & Internal Medicine

Associates

Family Allergy & Asthma

Family Health Center -

Iroquois

Family Health Center -

Portland

Family Medicine Clinic - ACB

Family Medicine Clinic -

Cardinal Station

Family Medicine Clinic -

Edison Center

Family Medicine Clinic -

Newburg

Family Medicine Clinic -

Sports Medicine @ Cardinal

Station

Family Medicine Residency

Clinic (Owensboro)

Fertility and Endocrine Assoc.

Fertility First

First Choice Ankle & Footcare

Center

First Urology - Dupont

First Urology, PSC -

Jeffersonville Main Office

Flaget Memorial Hospital

Foot & Ankle Specialists

Foot Doctors, PSC

Forefront Dermatology -

Downtown

Fort Wayne Medical

Education Program

Geriatric Medicine Clinic -

Central Station

Glasgow Pediatric Healthcare

Glasgow Radiology PSC

Global Health

Graves Gilbert Clinic

H. Lee Moffitt Cancer Center

and Research Institut

Health Department: Barren

County

Hermitage Care and Rehab

Holiwell Health Integrative

Medicine

Home of the Innocents

Hosparus Home Visit

Hosparus of Louisville

In-Training Exam - Family

Medicine

International - Amazon River

Valley, Manaus, Brazi

International - Bugando

Medical Center

International - Ghana

International - Hospital for

Sick Children, Canada

International - Lions Gate

Hospital, Vancouver, BC

International - Managua,

Nicaragua

International - Moshi,

Tanzania

International - Mzuzu Central

Hospital

International - Nairobi, Kenya

IU Health: Beltway Surgery

Center

IU Health: Methodist Hospital

IU Health: North Hospital

IU Health: Riley Hospital for

Children

IU Health: Sidney & Lois

Eskenazi Hospital

IU Health: University Hospital

JCPS High School Football

Jefferson County Attorney's

Office

Jeffersonville Pediatrics

Joint Endeavors, Specialists in

Rheumatology

Kentuckiana Allergy, PSC

Kentuckiana ENT

Kentucky Fertility Institute

Kentucky Lion's Eye Center

Kentucky Skin Cancer Center

Kentucky State Police -

Frankfort Crime Lab

Kentucky State Police

Frankfort Crime Lab

Kentucky State Police

Jefferson Crime Laboratory

KentuckyOne Health

Orthopedic Associates

Kilimanjaro Christian

Medical Center

Kindred Hospital of Louisville

at Jewish Hospital

Kleinert Kutz Downtown

Clinic (in Jewish OCC)

Kleinert Kutz Hand Care

Center

Kleinert Kutz New Albany

Clinic

Kosair Charities Pediatrics

Center

KY Office of Chief Medical

Examiner

Lake Cumberland Regional

Hospital

Lake Cumberland

Rheumatology - New Albany

Lee Specialty Clinic

LMPD - Crimes Against

Children Unit

Louisville Center for Eating

Disorders

Louisville Center for Voice

Care (ULP)

Louisville Family ENT

Louisville Metabolic and

Atherosclerosis Research

Louisville Metro EMS

Louisville Metro Public Health

Louisville Palliative Care

Louisville Surgical Assocs.

Marvin & McCrary Forensic

Evaluation Services

Masonic Homes of Kentucky:

Louisville Campus

Mayo Clinic

McPeak Vision Partners

Memorial Sloan Kettering

Cancer Center

Metro Specialty Surgery

Center

Midwest Access Project

Midwest Gastro Assoc

Mountain Home Veteran's

Affairs Medical Center

National Cancer Institute -

Cairo

National Institute of Health

(NIH)

NCMG - Brownsboro

NCMG - Genetics Center

NCMG - Norton Children's

Behavioral & Mental Healt

NCMG - Norton Children's

Development Center

NCMG - Norton Children's

Endocrinology

NCMG - Norton Children's

Hematology & Oncology

NCMG - Norton Children's

Medical Group - Stonestreet

NCMG - Norton Children's

Neonatology Specialists

NCMG - Norton Children's

Neurology

NCMG - Norton Children's

Pediatric Protection Spec

NCMG - Norton Children's

Autism Center

NCMG - Novak Center for

Children's Health

NCMG - Physical Medicine

and Rehabilitation

NCMG - Urology

Neurology @ ULPOC

NewYork Presbyterian, The

University Hospital of C

Next Step 2 Mental Health

NHC - National Healthcare

Corporation

Northern Light Eastern Maine

Medical Center

Norton 210 Gray St Bldg

(Private Practice)

Norton Audubon Hospital

Norton Brownsboro Hospital

Norton Cancer Institute -

Downtown

Norton Children's Hospital

Norton Children's Medical

Center - Brownsboro

Norton Children's Medical

Group

Norton CMA - Audubon

Norton CMA - Barret

Norton CMA - Brownsboro

Norton CMA - Bullitt County

Norton CMA - Dixie Hwy

Norton CMA - Fincastle

Norton CMA - Hurstbourne

Norton CMA - Lakeview

Norton CMA - Mallard Creek

Norton CMA - Mt.

Washington

Norton CMA - Preston

Norton CMA - Shelbyville

Norton CMA - Shepherdsville

Norton Healthcare Pavilion

Norton Hospital

Norton Immediate Care

Center - Highlands

Norton Leatherman Spine

Center

Norton Medical Plaza -

Brownsboro Crossing

Norton Medical Plaza - St.

Matthews

Norton Neurology Services

Norton Neuroscience Institute

Sports Neurology Cen

Norton Orthopedic Institute -

Angie's Way

Norton Orthopedic Institute -

Dutchman

Norton Sleep Medicine

Specialists

Norton Urogynecology Center

Norton Women's & Children's

Hospital

OBGYN @ ACB

OBGYN @ ULPOC

Office of the Commonwealth's

Attorney

Oldham County EMS

Oldham County Pediatrics

Orthopaedics @ ULPOC

Orthopedic Specialists

Other

Owensboro Dermatology

Associates

Owensboro Health

Breckenridge Medical

Building

Owensboro Health Outpatient

Imaging - The Springs

Owensboro Health Regional

Hospital

Park Duvalle Community

Health Center

Parsley/Waldman Hair Center

Pediatric Anaesthesia

Associates, PSC

Pediatric Rheumatology @

ULPOC

Pediatrics of Bullitt County

PGXL Laboratories

Physician Medical Center

(PMC) Outpatient Surgery

Physician's Medical Center

Physicians Eye Center

(Owensboro)

Premier Surgery Center

Private Practice

Prospect Internal Medicine

Psychiatry @ ULPOC

Research - Non VA Supported

Research - ULH Supported

Research - VA Supported

Rheumatology Associates.,

PLLC d/b/a Arthritis Ass

Richard L. Miller Oral Health

Clinic

River Ridge Surgical Suites,

Llc

Rond Schrader Clinic

Sacred Heart Home Village

Sellersburg Internal Medicine

& Pediatrics

Seven Counties Services -

Adult Downtown

Seven Counties Services -

Atkinson Elementary

Seven Counties Services -

Champions Trace

Seven Counties Services - East

Broadway

Shea Orthopedic Group

South Central Kentucky

Orthopaedics

South Louisville Pediatrics

Southern Indiana Rehab

Hospital

Southern Kentucky

Nephrology Associates

Springs Medical Center

St. Joseph's Hospital

(Lexington)

St. Vincent Hospitals and

Health Care Center

Suburban Excimer Laser

Center

Surgecenter of Louisville

TAPP - South Park

TAPP - Westport

Tate Institute for Female

Pelvic Health

Telluride Medical Center

Temple University Hospital

The Brook - Dupont

The Brook - Lagrange Road

The Center for Courageous

Kids

TJ Samson Community

Hospital

TJ Samson Family Medicine

Center

TJ Samson Health Partners

TJ Samson Health Pavilion

Total Healthcare for Women

Treyton Oak Towers

UK HealthCare Turfland

UL Athletics Athletic Training

Room

UL Sports Med @ Frazier

ULP - Urogynecology at M&E

ULP - Urogynecology at

Springs Medical Center

ULP - Urogynecology at

ULPOC

ULP Orthopaedics: Grey

Street

ULP Orthopaedics: Kresge

Way

University Dermatopathology,

PLLC

University Kidney Center 3rd

Street

University Kidney Center

Bluegrass

University of California San

Francisco

University of Chicago

University of Cincinnati

Barrett Cancer Center

University of Cincinnati

Medical Center

University of Kentucky

Chandler Medical Center

University of Louisville

Kidney Disease Building

University of Michigan Health

System

University of Texas MD

Anderson Cancer Center

University of Toronto

University of Washington

Medical Center

UofL Family Medicine MECH

UofL Health - Abraham

Flexner Outpatient Care Cent

UofL Health - Brown Cancer

Center (Downtown)

UofL Health - Chestnut St

Health Care Otpt Ctr

UofL Health - Frazier

Rehabilitation Institute

UofL Health - Jackson St Amb

Care Build

UofL Health - Jewish Hospital

UofL Health - Mary &

Elizabeth Hospital

UofL Health - Mary &

Elizabeth Hospital Plaza I

UofL Health - Medical Center

East

UofL Health - Medical Center

East

UofL Health - Medical Center

East (ULP)

UofL Health - Medical Center

Northeast

UofL Health - Medical Center

Northeast (ULP)

UofL Health - Medical Center

South

UofL Health - Medical Center

Southwest

UofL Health - Peace Hospital

Geriatric Unit at Fra

UofL Health - Shelbyville

Hospital

UofL Health - University of

Louisville Hospital

UofL Health-Frazier Rehab

Institute-Sports Med Ctr

UofL Pediatrics - Child &

Youth Clinic

UofL Pediatrics - Eastern

Parkway @ SSKCC

Uspiritus - Brooklawn

Vanderbilt University Medical

Center

Veterans Administration

Hospital: Indianapolis

Veterans Administration

Hospital: Lexington

Veterans Administration

Medical Center (RobleyRex)

Washington University (St.

Louis)

Women's First [in Baptist

Medical Pavilion]

Resident Policies and Procedures

Section XXXII

UNIVERSITY OF LOUISVILLE OFFICE OF GRADUATE MEDICAL EDUCATION

RADUATE MEDICAL EDUCATION COMMITTEE

RANSITION OF CARE AND HANDOFF POLICY

ACKGROUND

The Sponsoring Institution must ensure that participating sites engage residents/fellows in standardized

transitions of care consistent with the setting and type of patient care. (ACGME Institutional Requirement

III.B.3.b)

Effective communication is vital to safe and effective patient care. Many errors are related to ineffective

communication at the time of transition of care. In order to provide consistently excellent care, it is vitally

important that we communicate with one another consistently and effectively when the care of a patient is

handed off from one physician to another. This policy is meant to define the expected process involved in

transition of care.

All residents and faculty members must demonstrate responsiveness to patient needs that supersedes self-

interest. They must recognize that under certain circumstances, the best interests of the patient may be

served by transitioning that patient’s care to another qualified and rested provider. (ACGME Common

Program Requirement VI.A.7) It is also essential for residents and faculty members to do so by abiding by

the program’s current duty hour policy.

EFINITIONS (AS USED IN THIS POLICY)

Hand-off: the process of transferring patient information and knowledge, along with authority and

responsibility, from one clinical or team of clinicians to another clinician or team of clinicians during

routine changes of duty assignment, such as beginning/end of call, beginning/End of a rotation, and

situations where a physician must exit mid-shift, such as when released from duty due to illness, stress,

fatigue, or duty hour issues. Methods of hand-off include verbal only reports, verbal reports with note

taking, printed handouts containing relevant patient information, and computer/EMR information.

Transition of Care: Patient movement from one area or level of care to another, e.g. transfer of a patient

from the wards to the ICU or vice versa.

Signout (as defined by the Agency for Healthcare Research and Quality (AHRQ): the act of transmitting

information about the patient.

ROGRAM REQUIREMENTS

4. Each training program (residency and fellowship) must have a program specific policy addressing

transitions of care that is consistent with the ACGME Institutional, Common Program

Requirements, and this UofL GMEC Policy.

5. The policy must address how the program facilitates professional development for core faculty

members and residents/fellows regarding effective transitions of care (Institutional Requirement

III.B.3.a).

6. The program must review hand-off effectiveness at least annually during the annual program

evaluation meeting.

7. Each training program must design clinical assignments to minimize the number of transitions in

patient care. (ACGME Common Program Requirement VI.B.1)

8. Each program must ensure and monitor effective, structured hand-over processes to facilitate both

continuity of care and patient safety. (ACGME Common Program Requirement VI.B.2). The

program should develop such a policy and procedures emphasizing a structured approach

(Institutional Requirement III.B.3.b).

a. The policy must list the facilities/sites/services the program has responsibility for,

including when on elective rotations.

b. The policy must list the transition of care and hand-off events. If there is a standard time

and location for activities, it should be listed in the policy. If there is not a standard time

and/or location, information on how this is to be determined should be addressed.

c. The policy must list the minimum requirements for hand-off (specialty specific)

• Patient Information (name, age, room number, medical id number, important

elements of medical history, allergies, resuscitation status, family contacts)

• Current condition and care plan (pertinent diagnoses, diet, activity, planned

operations, significant events, current medications)

• Active issues (pending laboratory tests, x-rays, discharge or communication with

consultant, change in medication, overnight care issues, “to-do” list)

• Contingency plans (if/then statements)

• Name and contact number of responsible resident and attending physician; name and

contact number of resident/attending physician for back-up

• An opportunity to ask questions and review historical information.

d. Should responsibilities continue after a service to service transfer of patient

responsibility, such as courtesy visits or communication with the inpatient team for the

purpose of providing care after hospitalization, the responsibilities should be noted in the

policy.

9. The sponsoring institution must ensure the availability of schedules that inform all members of the

health care team of attending physicians and residents currently responsible for each patient’s care.

(ACGME Common Program Requirement VI.B.4) As noted in the GMEC Policy on Resident

Supervision, programs are responsible for creating a periodic call schedule, which clearly

identifies the primary on-call resident and the appropriate chain of supervision, including the name

of the supervisory attending physician. The schedule should contain pertinent information

(telephone number, beeper/pager number, etc.) necessary to quickly and efficiently contact the

members in the chain of command. Copies of the call schedule should be available to the

residents and the key personnel at the training sites (clinics, hospital operators, etc.). It is the

responsibility of the residency program to keep the call schedule current and accurate.

a. This is available via MedHub Assignment Schedule.

b. Effective July 1, 2012, all medicine fellowships are required to use MedHub for the

assignment schedule per the Chair’s Office.

10. The policy must state the level of faculty supervision and explain how progression of

responsibility occurs, as required in the UofL School of Medicine and the program specific

Policies on Resident Supervision and Evaluation, Promotion, and Termination. Faculty oversight

of the handoff process may occur directly or indirectly, depending on resident level and

experience.

• As required in the GMEC Policy on Resident Supervision, residents should be informed

that if they are at any time concerned about the availability or level of supervision, they

should contact their residency program director, the departmental chairperson, the

Associate Dean for Educational and Work Environment, the Resident ombudsman to the

Subcommittee on Resident Educational and Work Environment, or the office of Graduate

Medical Education of the University of Louisville School of Medicine.

11. Programs must ensure that residents are competent in communicating with team members in the

hand-over process. (ACGME Common Program Requirement VI.B.3).

This evaluation should be

documented and referenced as part of the program’s Evaluation, Promotion, and Termination

Policy.

12. The program procedure must maintain patient confidentiality. Sign out forms must never be sent

by unencrypted email, left in a publicly accessible mailbox or area, copied or sent to unauthorized

users, disposed of in non-confidential trash receptacles.

13. A copy of the program specific policy must be on file in the GME Office. The office of GME

must receive copies of any changes to this document.

14. A copy of the policy must be loaded into MedHub for individual faculty and resident signature.

Approved by GMEC: May 21, 2014

Residents Policies and Procedures

Section XXXIII

University of Louisville (UofL) Health Care Policy on Vendors

Approved, UofL Medical Council on July 23, 2008, Effective this date

This policy is intended to improve the educational environment at UofL Health

Care (i.e., University Hospital, the James Graham Brown Cancer Center, the

Kentucky Lions Eye Center and University Physicians Associates) for the faculty,

staff, and students, as well as the clinical care of their patients by reducing actual

and perceived conflicts of interest on their selection of treatment. This policy

applies to all hospital and office settings owned, operated by, or rented by UofL

Health Care where UofL medical students, residents, and fellows work, practice

medicine, conduct research, or are educated by University of Louisville-salaried

faculty. This policy reinforces and does not infringe on the existing function and

structures of the participation in clinical trials, clinical committees, or policies at

the University, including the Product Review Committee, the Pharmacy and

Therapeutics Committee, and the Conflict of Interest Policies:

(http://research.louisville.edu/policies/conflictofinterest.html and

http://www.louisville.edu/admin/humanr/policies/conflict.htm), which require the

disclosure and recusal of any person with any financial interest in a vendor’s

services. This policy has no standing at other hospitals not part of the University of

Louisville except as noted in Sections 2 and 8.

Vendors are defined as pharmaceutical company and medical equipment representatives, as well as

including equipment and service providers.

1. Gifting: Vendors may not make any form of gifts (whether cash or an item of any value) at UofL

Health Care, the School of Medicine, and all other clinical, administrative, educational, and research

venues and activities.

2. Detailing and Marketing: Vendors may not product or brand detail (i.e., in-person marketing

visits by vendors), or market, at UofL Health Care, the School of Medicine, and all other clinical,

administrative, educational, and research venues and activities. Vendors may not give any form of

food, cash, or material gifts between them (or their companies) and University of Louisville-salaried

faculty, staff, residents, fellows, and health care students in person, by phone, email, mail or any other

means at UofL Health Care premises or at any UofL affiliated educational sites. Displays of products, cash

incentive programs for prescribing, product pamphlets, pre-printed prescription pads with product names,

and other materials are prohibited. Detailing and marketing at hospitals and facilities outside of UofL

HealthCare and the School of Medicine will be governed by the policies and procedures of the individual

institutions.

3. Visits to faculty by appointment: This policy does allow for visits by appointment (as set forth by

protocols approved by individual administrative units — i.e., Departments, Divisions, etc.) for updates on

new products, education regarding existing products, discussions of support for unrestricted education

grants, and supply of pharmaceutical samples, competitive selection by clinical committees for new

products, services, or devices, and in-service training for products to faculty and staff that have been duly

deliberated upon and selected for use at UofL Health Care. Vendors, who each must be credentialed with

UofL Pharmacy or Operating Room, as applicable, will register with the inpatient pharmacy or the

operating room scheduler's desk prior to all UofL visits and will be issued an appropriate ID badge.

4. Educational Grants: This policy does allow for unrestricted educational topic-focused or general

grants from vendors for Continuing Medical Education (CME) and Graduate Medical Education

(GME) activities. Unrestricted educational grants from pharmaceutical companies and medical equipment

companies are allowed for the purchase of educational needs as warranted for patient and medical

education and patient care, either in an open (unspecified) manner or with acknowledgement that it is

focused on a specific area of educational focus. Additionally, these grants can be used for educational

related expenses (e.g., staff, resident, faculty lunch-based presentations). These CME symposia may not

involve marketing, detailing, or advertising of brand names or products, and the granting companies may

not select paid lecturers or require the inclusion or exclusion of medications purchased for patient care.

These symposia will comply with all CME regulations. CME symposia (i.e., ACGME accredited and in

compliance with ACGME guidelines) may provide food purchased with these grants. Vendors may restrict

the educational grant to cover specific educational topics (e.g., breast cancer or heart disease) so long as the

above listed requirements are met. Recognition of these grants may consist of attribution (e.g., in

brochures for conferences, graduation event agenda, acknowledgement slides in presentations, and wall

plaques of thanks) for contributions received.

a. Funds designated to specific units will be kept in designated unit accounts through the

Assistant Vice President for Finance, UofL Executive Vice President for Health Affairs

(EVPHA) office, with these funds channeled through a central administrative account, but with

separate accounts kept for each unit. Individual Departments of the School of Medicine will

administer these grants and will be responsible for their collection and expenditure. Annual

reporting of the receipt of such grants and their expenditure will be provided to the Dean of the

School of Medicine, Dentistry, or Nursing as appropriate. Any perceived violation of the

conditions outlined above will be reported to the appropriate Dean.

Residents Policies and Procedures

Section XXXI.

b. General grants (i.e., non-unit or topic specific) will be placed in trust within the Assistant

Vice President for Finance, UofL EVPHA office, and administered as deemed appropriate under

the supervision of a Faculty Oversight Committee elected from the Executive Faculty.

5. Pharmaceutical Samples: This policy does allow for pharmaceutical samples to be given to UofL

Health Care clinical sites. Acceptable sample medications will be articulated in a formulary in each

department as approved by each in consultation with UofL Pharmacy Services. Delivery of sample

medications may not be accompanied by any form of detailing or gifting. UofL Health Care is dedicated to

soon implementing a voucher plan with area pharmacies to mitigate the need for sample medications.

6. Vendors are not allowed into the following locations: patient care areas, operating rooms, delivery

rooms, emergency rooms, medical student and resident lounges, and staff elevators except only to provide

in-service training or assistance on devices and equipment, for example, in the operating room. In such

cases, there must be prior disclosure to and consent by the patient or surrogate (if the patient is

incapacitated) whenever possible, i.e., if it is known ahead of time that a vendor will be involved. However,

in such cases that crisis or emergency treatment with devices, equipment, etc. from a vendor is required

during an operation or procedure in order to provide the best care for the patient, and if the patient is

incapacitated and no surrogate is available, the requirement for consent will be waived.

7. Education programs for students, trainees, staff, and faculty should be developed and

implemented by UofL-HSC schools and by individual departments on vendor marketing, as well as

the subtle influences that such promotion has on physician decisions. If desired, one educational option

is to have a vendor provide an interpretation of educational material on products, which would then be

discussed and critiqued by a faculty member. Students may interact with vendors only in educational

forums, and only when accompanied by faculty supervision.

8. Off-Campus Vendor Relationships: While UofL-salaried faculty, staff, residents, fellows, and health

care students are personally prohibited from accepting any form of gifts, food, or products (of any type or

value) from vendors or their companies, at UofL Health Care Kentuckiana locations, other forms of

professional interaction, employment, and consulting do exist. Although this policy does not call for

institutional policing of off-site activities (i.e., vendor gifting in person, or by phone, e-mail, mail or any

other means at any time outside the UofL premises to faculty, staff, residents, fellows, and health care

students), adherence to the principles outlined in this policy is not reserved for duty hours.

a. Off campus, non-UofL endeavors (such as paid lectureships) are strongly discouraged.

Research relationships by UofL personnel are covered by this policy, as well as by the UofL

policy on Conflict of Interest. UofL personnel who are hired speakers for Vendors as well as all

researchers funded by any Vendor will fully disclose any potential commercial bias at all

presentations and interactions, will not allow their own relationship to bias the content of the

lecture, and will not accept payments from Vendors for their services above fair market value.

b. Travel funds may not be directly given to any UofL faculty, residents, or students, except

in the cases of legitimate reimbursement or contractual services to those Vendors. Travel

funds for educational purposes must be otherwise handled per Section 4.

c. It is recognized that members of the faculty may, in the course of their leadership roles in

non-profit professional and scientific organizations, be expected to participate in programs,

meetings, and events that involve Vendor relationships. Vendor interaction of UofL faculty

members in the course of representing legitimate professional organizations will be governed by

the policies and procedures of the specific organization.

9. UofL faculty, residents, or students are prohibited from engaging in any form of ‘ghostwriting’ of

any presentations, publications, or other forms of media product (i.e., the provision of materials by a

Vendor or intermediary that is officially credited to someone other than the writer(s) of the material).

10. Implementation and monitoring of this policy will be made at the administrative unit level (such

that surveillance and remediation of minor violations be managed on this basis). Major violations (as

determined by the unit administrative head) would be the purview of the appropriate Dean or his/her

appointed designee for action.

Resident Policies and Procedures Manual

Section XXXIV

UNIVERSITY OF LOUISVILLE SCHOOL OF MEDICINE

INCLEMENT WEATHER POLICY AND PROCEDURE

Background (Intent)

The University of Louisville, as a Sponsoring Institution, in partnership with its training programs, must

ensure and monitor processes to facilitate both continuity of care and patient safety.

Definitions (As used in this Document)

Resident: Any physician in a University of Louisville graduate medical education program recognized by

the GME Office, including interns, residents, and fellows. Residents in University of Louisville

School of Medicine training programs are classified as students (see item #7 in the Resident

Agreement).

Policy

1. If the University of Louisville closes or makes a decision to cancel classes or is operating on a

delayed schedule, School of Medicine students follow the Inclement Weather Policy for Medical

School Courses and Clerkships.

2. University closure or delay has no effect on resident and fellow work schedules. Faculty,

Residents and Fellows are responsible for ensuring that all patient care obligations are met

regardless of inclement weather.

Procedure

1. In the event of adverse weather, whether or not the University is closed or delayed, all residents

and fellows assigned to inpatient rotations are to report and/or speak with their attending or

supervising resident.

2. Residents and fellows assigned to an outpatient rotation or continuity clinic are to report unless

clinics have been closed. If weather is severe enough to warrant closure of clinics, an

announcement will be made through the specific clinic.

a. University of Louisville Physicians (ULP) has their own policy regarding the clinics and

the information is on the ULP site: www.UofLPhysicians.com

b. As many of our Veterans travel over 100 miles to come to the VA and may not be aware

of the weather conditions in Louisville or be able to receive a cancellation in a timely

manner (before they leave home), the VA clinics normally remain open during adverse

weather conditions. However, on extremely rare occasions, a decision may be made to

close the clinics for the VA. This will be posted on the Robley Rex VA Internet site:

http://www.louisville.va.gov/

c. Clinic closings may (or may not) be posted on television stations.

References & Related Policies

University of Louisville Inclement Weather Policy for Medical School Courses and Clerkships.

University of Louisville Severe Weather Policy & Procedures http://louisville.edu/weather

Approval

Approved by GMEC: November 18, 2015

Revised January 21, 2016

Revision approved by GMEC: April 1, 2019

Resident Policies and Procedures Manual

Section XXXV

UNIVERSITY OF LOUISVILLE

SCHOOL OF MEDICINE

WORKERS’ COMPENSATION INFORMATION FOR OCCUPATIONAL INJURIES AND

EXPOSURES INCLUDING NEEDLESTICKS AND TUBERCULOSIS

EFFECTIVE MARCH 1, 2022, EMPLOYEES WHO ARE INJURED ON THE JOB AND ARE

SEEKING MEDICAL TREATMENT MAY SEE THE PHYSICIAN OR PROVIDER OF THEIR

CHOICE.

IF THE EMPLOYEE NEEDS IMMEDIATE MEDICAL ATTENTION, THEY MAY GO TO ANY

EMERGENCY FACILITY.

Claims should be reported to Risk Management as quickly as possible. Please note: If the accident or

injury involved an overt exposure to recombinant DNA molecules, the Department of Environmental

Health & Safety (DEHS) must be notified immediately by phone (852-6670). After work hours contact the

Department of Public Safety (DPS) at 852-6111. UofL is required to notify NIH/OBA of the incident

immediately as directed by the NIH Guidelines.

It is the employee’s responsibility to immediately report their injury to their supervisor. It is then the

supervisor’s responsibility to immediately complete the online reporting system and submit the report to

Risk Management.

The Work Comp Claim reporting system can be accessed from the Enterprise Risk Management website at

https://louisville.edu/riskmanagement or by clicking here

Please make sure all claims are reported in a timely manner. Late or delayed reporting of a claim could

jeopardize the compensability of the claim.

It is the injured employee’s responsibility to make an appointment for treatment. It is also the injured

employee's responsibility to notify their department each time their treating physician takes them off work

due to their work-related injury or illness. The employee’s supervisor should in turn notify Risk

Management when an employee is off work due to an injury or has doctor-imposed work restrictions.

Workers Compensation will begin paying compensation after the employee has been off work due to a

work-related injury or illness for at least seven (7) consecutive calendar days. If the employee is off work

for more than fourteen (14) consecutive calendar days, compensation is also payable for the first seven (7)

calendar days of the injury. Workers Compensation only pays for full days off work, at the direction (in

writing) of the treating physician. Workers Compensation does not pay for time off work for a doctor's

visit, physical therapy, or medical testing. The amount of pay from Workers Compensation is two-thirds

(2/3) of the employee’s weekly pay. Sick and/or vacation leave may be used to bring the total

compensation from all sources up to the amount of the employee’s regular pay.

If the claim is denied by Workers Compensation, the employee, or their health insurance, is responsible for

any payments, including doctor bills, emergency room charges, etc.

If the employee will be off work for three (3) or more consecutive days, the employee is required to apply

for Family and Medical Leave. If the employee anticipates missing six (6) months or more of work, they

may want to file a claim for Long Term Disability (LTD) benefits. For additional information on Family

Medical Leave or Long-Term Disability benefits please contact University Human Resources

http://louisville.edu/hr/. Residents and Fellows should refer to the Leave of Absence in policy in the

current Resident Policies and Procedures Manual.

Workers Compensation Information for Needle Stick and Tuberculosis Exposures

You may be seen at the following locations for needle sticks and tuberculosis exposures that are work-

Student Health Services University of Louisville

UofL Health Care Outpatient Center Belknap Health Services Office

401 East Chestnut St., Suite 110 2207 S. Brook Street

Louisville, KY 40202 Louisville, KY 40292

(502) 852-6446 (502) 852-6479

(Answered 24 hours a day) Mon. – Fri. 8:30am – 4:30 pm

Mon. – Fri. 8:30am – 4:30 pm

Resident Policies and Procedures Manual

Section XXXVI

UNIVERSITY OF LOUISVILLE GRADUATE MEDICAL EDUCATION

INFORMATION ON BOARD ELIGIBILITY

BACKGROUND (INTENT)

The Sponsoring Institution must insure that residents are provided information related to eligibility for

specialty board examinations (ACGME Institutional Requirements IV.C.2.k). The resident contract also

references this information.

Information about Board Eligibility

Board certification following graduate medical education is a measure of quality for the program and the

trainee. UofL-sponsored GME programs expect their trainees to commit to becoming board certified upon

completion of their training.

Boards vary in their requirements regarding board eligibility and certification. A number of challenges to

an individual’s eligibility for board certification can be encountered during GME training, and the effect of

leaves of absence, for any reason, taken during residents’ training on their eligibility and the timing for

board certification should be known and understood by the resident/fellow.

Residents and fellows are strongly advised to access the specific relevant information from their certifying

boards, available via the website for the American Board of Medical Specialties www.abms.org

and to

maintain familiarity with the appropriate requirements in order to avoid unforeseen delays in their board

certification.