Forms

Contacts

Robbin Bankston

Program/Office Manager

RBankston@stanfordhealthcare.org

650-736-7487 (office)

Marcy Kulakow, BA

Registrar

MKulakow@stanfordhealthcare.org

650-723-5948 (office)

Mitra Haddad, BA

Administrative Coordinator

MHaddad@stanfordhealthcare.org

650-723-5948 (office)

Last Revised 1/23/2018

Forms
Form Deadline Contact Person Note

Away Rotation Application

 60 days prior to the start of a new away rotation Mitra Haddad
  • House Staff must reach out to Program Director and Program Coordinator regarding away rotation logistics, such as funding and application submission.
  • Then Program Coordinator works closely with the house staff to submit the away rotation request to GME.
  • See Policies & Procedures: Away Elections/Rotations.
Checkout Form for House Staff last day of training Mitra Haddad
Leave of Absence (LOA) Form
 30-45 days prior to your first day of leave Robbin Bankston
  • Types of LOAs: Bereavement, Family Leave, Jury Duty, Medical Leave (Non Pregnancy, Pregnancy), Paternity, Personal Leave.
  • Prior to working with Matrix, please submit completed GME LOA Form with your Program Director’s signature to Ann Dohn, GME Director, DIO for approval.
  • Review the Matrix form here.
  • See Policies & Procedures: Leave of Absence.
Life Support Training Center (LSTC) Registration Form as needed Fax to the GME Office 650-723-3045 or e-mail to gme@med.stanford.edu
  • The GME Office will NOT reimburse you if you pay out of pocket. You must submit the completed LSTC-GME Payment Authorization form for Approval/Sponsorship for payment 3 weeks prior to enrolling in the class.
  • Additionally, the GME Office does not fund or reimburse registration for lapsed recertification’s OR for graduating house staff.
  • See Policies & Procedures: Mandatory Procedures.
Live Scan Service Request submit form with CA MD License processing -
Reimbursement Form Varies,
please read the form carefully		 Mitra Haddad
Sharps Training Checklist September Occupational Health  
Welch Road Apartment Application Form Before May 1st gme@med.stanford.edu