To be completed by Pediatrics Department, at least 180 days prior to start date of Clinical appointment.
* indicates required fields.
Administrative Contact *
Administrative Contact Email: *
Information needed to determine approval of appointment.
Medical Fellow - OPA
Dates of appointment: *
Brief Description of Research/Training to Be Completed *
PTA/Grant Manager's Name (000000-000-ABCDE if PTA not known): *
PGY Level *
full patient care responsibilities
incidental patient contact
current status (ie: postdoc, ACGME Fellow) *
visa type to be requested *
if requesting a visa, PTA for visa processing (unrestricted only)
Fellow's non-Stanford Email (email never used @ Stanford) *
Please skip. Do not fill this out.