PedsClinicalFellowOPAwebform

To be completed by Pediatrics Department, at least 180 days prior to start date of Clinical appointment.

* indicates required fields.

Faculty Sponsor Name *

First

Last

Division *

Email *

Administrative Contact *

Administrative Contact Email: *

Fellow Information Required

Information needed to determine approval of appointment.

Appointment Type

Fellow Name *

First

Last

Dates of appointment: *

Brief Description of Research/Training to Be Completed *

Fellowship/Stipend amount:

Salary amount:

PTA/Grant Manager's Name (000000-000-ABCDE if PTA not known): *

PGY Level *

Patient Contact *

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) *

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