Personal Data Change Form

Places This Form is Referenced

• Page:
  GME Program Exit Packet (Forms & Documents) —

  Instructions for Completing Form

  This packet is to be completed for each House Officer not continuing with the program (ex. graduating, transferring, and terminating) and sent to the GME office (GME Electronic Submission Site )within 30 days of departure with the checklist. (Scans can be sent to gme@lsuhsc.edu) NOTE:  If a resident is OFF CYCLE, please send the packet to the GME office within 30 days of departure.

  Other Info

  The following items should be included in the packet (or check off the checklist to indicate they were completed):

  • Copy of diploma, resignation letter, or supporting documents

  • Updated GME Data Sheet (Must include all training/jobs/LOA from Medical School thru Residency/fellow training including training completed or leaving if not completed.)

  • Procedure log/Case log summary (if applicable, Summary listing)

  • Summative Letter Template

  • GME Verification Letter

  • Copy of Personal Data Change Form (original should be sent directly to Human Resources).  If no address change, put NA on the form and include in packet. https://www.lsuhsc.edu/ps/support/docs/Employee%20Self%20Service/2025%20Docs/1NO/Create_a_Personal_Data_Change.pdf

  • For Program records/Action Items: 

    • Duty Hour Compliance Report showing up to date completion saved in program files.

      • Core Curriculum / AMA GCEP completion summary report saved in program files.

      • Copy of updated CV saved in program house officer files

      • Copy of completed LCMC Health_EXIT-House Staff Clearance Form_5.2025.pdf

      • Verify the resident’s file is complete and organized according to the House Officer Portfolio Checklist

• Page:
  Personal Data Change Form (Forms & Documents)