Residency Elective in Health Policy – Program Director Approval | Kaiser Permanente Undergraduate & Graduate Medical Education Northern California

Do you want to submit response for more than one resident or fellow at this time?*

Yes
No

Resident/Fellow's Name*

First Last

I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 3, 2022 - Friday, October 14, 2022.*

Yes, the resident/fellow can attend.
No, the resident/fellow cannot attend.
Other

If "Other" was selected, please explain below.*

Additional Resident and/or Fellow Approvals

You can submit response for up to 5 additional residents/fellows.

(2) Resident/Fellow's Name*

First Last

(2) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 3, 2022 - Friday, October 14, 2022.*

Yes, the resident/fellow can attend.
No, the resident/fellow cannot attend.
Other

If "Other" was selected, please explain below.*

(3) Resident/Fellow's Name

First Last

(3) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 3, 2022 - Friday, October 14, 2022.

Yes, the resident/fellow can attend.
No, the resident/fellow cannot attend.
Other

If "Other" was selected, please explain below.*

(4) Resident/Fellow's Name

First Last

(4) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 3, 2022 - Friday, October 14, 2022.

Yes, the resident/fellow can attend.
No, the resident/fellow cannot attend.
Other

If "Other" was selected, please explain below.*

(5) Resident/Fellow's Name

First Last

(5) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 3, 2022 - Friday, October 14, 2022.

Yes, the resident/fellow can attend.
No, the resident/fellow cannot attend.
Other

If "Other" was selected, please explain below.*

(6) Resident/Fellow's Name

First Last

(6) I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 3, 2022 - Friday, October 14, 2022.

Yes, the resident/fellow can attend.
No, the resident/fellow cannot attend.
Other

If "Other" was selected, please explain below.*

Program Director Details

Your Name*

First Last

Your Email*

Your Specialty/Program*

If you selected "Other" Specialty/Program, please provide specialty/program name.*

Medical Center*

If "Other" Medical Center selected, please provide the center's name.*

KP Region*

Your Phone*

Program Director Approval – KPNC Residency Elective in Health Policy

Complete this form for your resident/fellow applicant(s). ALL applicants must have their PD approval to be considered for the course.

Additional Resident and/or Fellow Approvals

Program Director Details