Appendix T – Application for Away Rotation

Page 1
Section 4
Assignment of Rotating Residents or
Fellows
4.4 Application for Residents Rotating to l
Page 1 of 4
Other Institutions
Date Revised: January 2001, November
2009, January 2015, May 2025
Application Procedure for
SSM Health/Saint Louis University School of Medicine Residents (SSM Health/SLUSOM)
Rotating to Other Institutions for Electives
External elective rotations for residents and fellows of SSM Health/SLUSOM’s Graduate Medical Education
(GME) Programs are only available on a case by case basis and with prior approval.
Applications will be
considered only for educational experiences which cannot be provided at SSM Health/SLUSOM or one of its
affiliated institutions. The electives should be for specific educational components which are critical to the
trainees’ future professional development.
Applications will only be considered from trainees who have already demonstrated mastery of PGY level goals
and objectives and have met or made substantial progress towards specialty or subspecialty board certification.
Because of the nature of funding for Graduate Medical Education, neither SSM Health nor its affiliated institutions
can receive Medicare or Medicaid reimbursement for stipends, benefits, malpractice, or other teaching and
administrative costs while one of our trainees is away on an elective. (See Section 1.5 subsection III, Funding
for Residency Training Programs). The malpractice coverage for trainees must be secured in advance while
training at a new clinical site or new institution (see Health Professions Letter of Indemnity). Malpractice coverage
is not available for non U.S. rotation sites.
The accepting institution for an elective is rarely able to receive governmental support for the above costs no
Medicare or Medicaid cost report, BBA 97 restrictions, etc.). For these and other reasons, alternative funding
and/or GME approval must be secured in advance of the away rotation experience.
Planning for these electives typically takes 3-6 months. Even funded and otherwise acceptable requests may
not be approved if the initial completed request (Section I-II, see below) is not received 3 months prior to the
projected start date of the elective.
Application procedures are as follows:

1. A separate application must be completed for each elective rotation.
2. Each application must be completed including resident data verifications and appropriate
   signatures before approval is given.

Applicant is to complete Section I of the application and is responsible for requesting completion of
Section II by the SSM Health/SLUSOM Residency Program Director. Applicant will then forward the
application to the Residency Program Director or Clinical Supervisor where the elective will be take for
completion of Section III and returned to the SSM Health/SLUSOM Residency Program Director.
The Program Director will forward the application to the SSM Health/SLUSOM Medicine GME Office for
completion of Section IV.
The original is to be kept in the SSM Health/SLUSOM GME office and copies forwarded to the applicant
and the elective residency program director.

Page 2
Section 4
Assignment of Rotating Residents or
Fellows
4.4 Application for Residents Rotating to
Other Institutions
Date Revised: January 2001, January
2015, May 2025
Page 2 of 4
Application For SSM Health/Saint Louis University School of Medicine Trainees
Rotating to Other Institutions for Electives
Directions: Complete Section I
Return application to:
SSM Health/Saint Louis University Program Director
Address
City, State, Zip Code
To be completed by applicant
Section I
Trainee Name:
Trainee Address:
(Last)
(First)
(Street, including Apartment Number)
(City)
Telephone:_-
(State)
Name of clinical site/location for away elective:
Purpose of this away elective (check all that apply)
observation only
clinical care
research
other (explain) -
(Middle)
(Zip Code)
PGY Level:
inpatient (list site
operative/procedures (list site
ambulatory (list site

• other clinical (list site_
  Address of program/clinical site of away elective.
  If outside of Missouri, will a state medical license be needed
  Yes
  No
  If Yes, who will process the license: Away Site Trainee/Trainee Program
  Phone number of program/clinical site of away elective.
  Name/Title of clinical supervisor at away elective site
  Phone number of clinical supervisor at away elective site_
  Email address of clinical supervisor at away elective site_
  Requested dates of rotation:
  Trainee’s signature:
  Date:

Page 3
Section 4
Assignment of Rotating Residents or
Fellows
4.4 Application for Residents Rotating to
Other Institutions
Date Revised: January 2001, January 2015,
April 2025
Page 3 of 4
Section II To be completed by applicant’s SSM Health/ SLUSOM Program Director
1.
The trainee is in good standing with the residency program _
Yes
_ No
2.
On the dates requested for rotation, the resident is a PGY _ level.
3.
An evaluation of trainee performance will be required at the end of the rotation.
Yes
_No
4.
Trainee will get credit for rotation toward ACGME program requirements
Yes
No
5.
Away experience is unique or not available at current/affiliated program sites _
6.
Away site is an SSM Health location _Yes_No
7.
Away clinical supervisor is an SSM Health physician Yes
No
8.
External funding available for away elective time Yes (source:
→ —No
9.
Away rotation is —
_ Full Time -
_ Part Time (describe duty time
10. Goals/Objectives specific for this rotation are expected and are listed below or attached
_ No
11.
• Away Rotation Goals:
• Away Rotation Objectives:
Program-specific policy for Away Electives is attached or completed using below link _
Yes
https://slu.az1.qualtrics.com/ife/form/SV_0j0FmNidYv3go3s
_No
SSM Health/SLUSOM Resident Program Director (Print)
SSM Health/SLUSOM Residency Program Director (Signature)
Date

Page 4
Section 4
Assignment of Rotating Residents or
Fellows
4.4 Application for Residents Rotating to
Other Institutions
Date Revised: January 2001, January 2015,
April 2025
Page 3 of 4
Section III To be completed by the Residency Program Directoror Clinical Supervisor at the Away
Elective site. After completion, please send this application to the applicant’s SSM
Health/SLUSOM Residency Program Director.

1. The resident has approval to take this elective rotation indicated below. _ Yes
   No
   Dates of rotation:

Will an ACME Program Letter of Agreement or Institutional Affiliation Agreement be required for this
Away Rotation -
Yes
No
3.
Will malpractice coverage be provided by the Away Elective Site _Yes_No
For non-Missouri sites: will a state training license be needed _
_Yes No
5. Name of residency program director (if applicable)
Name of sponsoring institution (if applicable).
Name of physician supervising resident:
(Print)
(Signature)
Date
Name of DIO/Site/Hospital/Institutional Official:
(Print)
(Signature)
Date

Page 5
Section 4
Assignment of Rotating Residents or
Fellows
4.4 Application for Residents Rotating to
Other Institutions
Date Revised: January 2001, January
2015, April 2025
Page 4 of 4
Section IV To be completed by SSM Health/ SLUSOM Administration.

1. Malpractice insurance
   is not extended to cover the resident while the resident is on this elective
   rotation. (See attached Letter of Indemnity.)
2. The resident has our approval to take this elective.
   Sr. Associate Dean, SSM Health/Saint Louis University School of Medicine
   Date
   SSM Health/Saint Louis University School of Medicine
   Name of Sponsor
   1402 South Grand Boulevard, Room M260
   Mailing Address
   St. Louis, Missour 63104
   City, State, Zip Code
   314-617-2359
   Telephone
   314-617-2534
   Fax
   FOR SSM Health / SLUSOM GME Office:
   Please check off:
   Copies sent by SSM Health/SLUSOM to:
   Applicant
   SSM Health/SLUSOM Residency Program Director
   Elective Program/Rotation Director