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

Resident/Fellow's Name*

First Last

Current Year of Training (indicate year of training at the time of course)*

If "Other" PGY Level selected, please explain.

Specialty*

If "Other" Specialty selected, please provide the specialty name.

Medical Center*

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

Region*

If "Other" Region selected, please explain.

Your Name*

First Last

Your Specialty/Program*

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

Your Email*

Your Phone*

I verify that the above applicant is in good standing and has been granted protected release time to participate from Monday, October 7, 2019 - Friday, October 18, 2019.*

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

If you answered 'other' to the above, please explain.