Verification Of Residency Training Form - State Of Connecticut Department Of Public Health
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1STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
VERIFICATION OF RESIDENCY TRAINING FORM
Applicant: Enter your full name and birth date on this form and forward it to the Chief of Staff or Program Director at the facility in
which you completed your residency training. This form must be completed by the facility and returned directly to this office.
Applicant’s Name: ________
Date of Birth: __
____________________________________________
______________________
Chief of Staff/Program Director: Please provide the following verification of residency training for the above named Connecticut
physician licensure applicant.
1. Name of facility where residency training was completed:
_______________________________________________________
2. Dates of participation: From ______________________________ To ______________________________
(month/day/year)
(month/day/year)
3. In what specialty was the residency training completed:____________________________________________
4. At what level(s) was this residency completed (PGY1, PGY2, etc.)?__________________________________
5. At the time of the individual’s training, was the residency training program in this specialty area accredited by the
Accreditation Council for Graduate Medical Education (ACGME), American Osteopathic Association (AOA) or The
Royal College of Physicians and Surgeons of Canada (RCPSC)? _______ (YES or NO)
6. Did this individual satisfactorily complete this period of residency training? _______ (YES or NO)*
7. Was this individual ever placed on probation? _______ (YES or NO)*
8. Was this individual ever disciplined or placed under investigation? _______ (YES or NO)*
9. Were any limitations or special requirements placed upon this individual because of questions of academic incompetence,
disciplinary problems or any other reason? _______ (YES or NO)*
*If you answered” No” to question 6 or “Yes” to questions 7-9, please provide details and or attach any documents you may have on
file regarding such information.
I, ______________________________________, being duly sworn, do depose and certify that I am the Chief of Staff/Program
Director at:
Name of Facility:
_________________________________________________________
Address:
_________________________________________________________
____________________________________________________
Telephone Number: (
Email:
______ ) ______________________
_______________________________________
I certify that the information above is an accurate account of the individual’s record and is true and correct.
____________________________________
_______________
Signature of Chief of Staff/Program Director
Date
Please return this form directly to:
Connecticut Department of Public Health
Physician Licensure
410 Capitol Ave, MS#12APP
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 707-1931
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