NCC Program Directors and their designated representatives are authorized to initiate a request for a Memorandum of Understanding (Agreement) with an outside institution by entering the required information in the fields below. Please ensure the contact information for the participating institution is correct to avoid delays in processing. Once submitted, all NCC agreements must be presented to the Graduate Medical Education Committee (GMEC) for review and approval so please submit requests at least 45 days prior to the anticipated start of the first clinical rotation. The requestor will be notified once the agreement has been fully executed. Send inquiries to: gmeagreements@usuhs.mil.

Program:

Requestor's Rank, Full Name, branch of service:

Title (Program Director must authorize ALL requests):

Note: All MOU requests involving subspecialty programs require the approval from the core program's Program Director. This is to ensure that the educational experience of the core program trainee will not be negatively affected.

Request has Program Director approval?:

Requestor's email address:

Name of institution with which the agreement is to be established:

New or renewal:

Required or elective:

Is this request for a one-time only clinical rotation:

If "yes", name and rank of trainee:

If "yes", dates of training:

Is the training currently offered by the NCC?:

Will the training take the place of a currently established rotation?:

Describe proposed funding source(s)?:

Other proposed funding source:

Point of Contact Information for the participating institution's designated program director, preceptor or administrator authorized to approve the agreement.

Name (First, M.I., Last):

Degree/credentials (if any):

Complete Mailing address:

Commercial phone number:

Email address:

Remarks: Please provide a brief justification for the agreement or any other pertinent remarks. At a minimum describe how the trainee(s) will benefit from the educational experience.