Form must be completed and signed
New Hire Packet – HR Forms Cont'd
HR-9 Form W-4
Federal Withholding tax form must be completed and signed. Do not include the worksheet.
Supplemental Form W-4

This form is for Information only for the House Officer and is NOT to be included in the New Hire Packet submitted to the GME Office
HR-10 Form L-4
State Withholding tax form must be completed and signed. Do not include the worksheet.
HR-11 Act 372-Selective Service Registration for Hiring
The form requires that any male who is required to register with selective service for a federal draft must do so before he is eligible to be hired as either a state classified or unclassified position

The form must be completed and signed if applicable

If the form is not applicable, leave it blank and include in the New Hire Packet

HR-12 Data Protection Form
The form allows the House Officer the option of protecting their home address and telephone number from being released as described under the Public Records Act.

The form must be completed and signed

HR-13 Direct Deposit Form
Direct Deposit is Mandatory.

If the house officer's account has checks, a voided check must be attached

If the house officer's account does not have checks, a form from the bank with account information must be attached

The form must be completed and signed

Benefit Enrollment Deadline Information on HR website – Residents (House Officers) New Hire Forms This form is for Information only for the House Officer and is NOT to be included in the New Hire Packet submitted to the GME Office
ACA Healthcare Marketplace Notice
This form is for Information only for the House Officer and is NOT to be included in the New Hire Packet submitted to the GME Office

Other Documents/Forms required by the GME Office
Training Verification - These forms & documents MUST be part of the New Hire's file and attached in New Innovations. If copies are available when submitting the New Hire packet, include with the packet.

Copy of Medical School Certificate/Diploma

Copy of ECFMG Certification - for all foreign Medical School graduates

Copy of Internship Certificate/Diploma if internship year is not part of completed Residency program

Other Documents/Forms required by the GME Office Cont'd
Copy of Residency Certificate/Diploma

Written Verification of Performance including Performance in the six competencies – from previous program (needed only if accepted to LSU from another program)

Flu Shots – All house officers are required to either get a flu shot; or they must complete the required form and must wear a mask while in patient care during annual flu season (October – March).

Flu shots are available annually at many of the hospitals house officers rotate to each month or at the annual flu shot fair at LSU. Information on Flu shot fairs will be distributed to all coordinators and program directors. The GME office does not offer free flu shots for residents

The GME Office needs documentation that includes the influenza vaccination name and lot number along with the date and location of receipt.

Coordinators MUST collect from each house officer a copy of the card received or any other detailed documentation/form from the hospital or clinic location that administered the flu shot. Do not send a copy of the "flu" sticker on the ID.

House Officers that decline receiving a Flu shot: Coordinators must collect from the House Officers the document/form the house officers signed declining the flu shot and send the document/form to the GME Office.

Medical License or Permit to Practice Medicine in Louisiana – All House Officers must have a valid Louisiana Medical License or Louisiana Permit issued by the Louisiana State Board of Medical Examiners (LSBME).

House Officers that DO NOT have a valid Louisiana License or Permit July 1 or on their start date, will not be able to begin training. This will cause changes to their training dates, and appointment dates in NI and the coordinator will have to update NI, reprint and re-submit forms to the GME Office.

The New Hire House Officer MUST begin the license/permit application process as soon as he/she is notified they have matched or have been accepted into the residency/fellowship training program.

LSU Senior Medical Students that Match in LSU Training programs attend the License Application Fair day held by the LSBME and the LSU GME Office. At this fair the LSU Senior student submits their Intern Permit application to the LSBME. If the student does not attend the fair, he/she must attend the fair at Tulane Medical School, if one is scheduled, or print the application from the LSBME website and submit the application and other required documents to the LSBME at least 3 months prior to July 1 or their start date.

Licenses from other states are NOT accepted.

Permits issued by LSBME expire in June, but there are some exceptions. House Officers MUST renew the Permit, if they have not received an unrestricted license, before the permit expires.

Unrestricted Medical License expires the month of the House Officers birth month. House Officers MUST renew the medical license before the expiration date.

Malpractice Form

The form is on the GME website and is submitted to the GME Office every year.

Coordinators print the auto-populated spreadsheets, attach them to the Malpractice form, and submit the form and the spreadsheets to the GME Office for signature. The first spreadsheet lists the house officers in the training program; the second spreadsheet lists the hospitals/training sites the house officers will rotate to during the academic year.

Other Documents/Forms required by the GME Office Cont'd
The GME Office submits the signed form and attached spreadsheets to the Risk Management Office.

The risk management office may request changes or more information if needed.

If there are changes to the roster of house officers in the training program and/or the hospitals/training sites, the information is updated in NI and a new form and spreadsheets are printed and submitted to the GME Office.

Appointment Form

The form is required by the GME office and lists all House Officers in the training program for the Academic Year.

The data on the form auto-populates from New Innovations

See the Instructions-Appointment Form & Spreadsheets document.

Spreadsheets

Spreadsheets are required by the GME Office and lists all House Officers that are:

Promoting to the next House Officer level, July 1 & Off-Cycle

Terminating June 30, or Off-Cycle

Transferring to another LSU program, July 1 or Off-Cycle

Becoming Faculty immediately after graduating from residency/fellowship training program

See the Instructions-Appointment form & Spreadsheets document Items to Re-Check before submitting New Hire Paperwork

GME-2 – Personal Data Sheet for GME
Only the first page is submitted for New Hires that graduated between May & June of Appointment year

Pages 1 and 2 are submitted for New Hires that graduated before May of the Appointment year

Page 2 includes all training/activities/etc. for dates beginning after Medical School graduation until Appointment date, (this includes leave of absence, time taken off to prepare for exams, or travel).

New Hire signed and dated the form

HR-1 - Biographical Data Page
Medical School name, graduation date, and degree included

Other advanced degrees, school name, and graduation date included if applicable

HR-2 – Employment Eligibility Verification Form (I-9 Form)
House Officer signed the form

Documents viewed are listed under the correction List (List A or List B & List C)

Dates and name written in the format requested and appear on all pages

Certification Section, Section 2, is completed by Coordinator

Certification Section, Section 2, the House Officer's appointment date is n the date section and NOT the date the form was completed

Certification Section, Section 2, is signed by the Coordinator

All requested information is included on the form

HR-4 – Drug Screen Clearance Email notification
Email is included in the New Hire Packet

HR-5 – Drug Screen: Agreement to Submit to Drug/Alcohol Testing Form
Completed and signed form is included in the New Hire Packet

Other
All forms requiring a signature are signed. No electronic signatures

Documents are included in the New Hire Packet for all forms requiring additional documents

Tax forms, W-4 and L-4 are included n the Packet

Checklist is attached to the Packet

Forms are in the order listed on the Check list.

Send ONLY completed packets to the GME Office. Send packets as soon as they are completed, do not hold until all New Hires have returned packets.

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