USF Research Scholars Scholar Name_________________________________ MEDICAL DOCTORS (ALIEN PHYSICIANS): If the Visitor is a medical doctor engaging in graduate medical training at USF, please contact Clinical Affairs at 974-9744 for information regarding ECFMG involvement. If the Exchange Visitor is a medical doctor engaging in a project which is predominantly related to observation, consultation, teaching, or research with no element of patient contact or only incidental patient contact, please complete this page. This verification memo must be signed by both your department chair and by the Dean of the College of Medicine, before being forwarded to Faculty Affairs. Please check the following as applicable: __ A. NO PATIENT CARE This certifies that the program in which the Exchange Visitor named above is to be engaged is solely for the purpose of observation, consultation, teaching, or research and that no element of patient care services is involved. __ B. INCIDENTAL PATIENT CARE (Only Foreign Medical Graduates) 1. This certifies that the program in which the Exchange Visitor named above is to be engaged is predominantly for the purpose of observation consultation, teaching, or research; 2. Any incidental patient contact involving the alien physician will be under the direct supervision of a physician who is a U.S. citizen or resident alien who is licensed to practice medicine in the state of Florida; 3. The alien physician will not be given final responsibility for the diagnosis and treatment of patients; 4. Any activities of the alien physician will conform fully with state licensing requirements and regulations for medical and health care professionals in the state of Florida; and 5. Any experience gained in this program will not be creditable toward any clinical requirements for medical specialty board certification. USF DEPT. CHAIR: ________________________________________________ Signature: _____________________________________ Date: ______________ Dean/College of Medicine: Signature: _____________________________________ Date: ______________