Physician/Surgeon: Residency Verification

Public Health: Verification Of Residency Training Form

DPH Data Management and Governance (PLIS)
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:

MonthDayYear
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

MonthDayYear
To

MonthDayYear
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)?
6. Did this individual satisfactorily complete this period of residency training?
7. Was this individual ever placed on probation?
8. Was this individual ever disciplined or placed under investigation?
9. Were any limitations or special requirements placed upon this individual because of questions of academic incompetence, disciplinary problems or any other reason?
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, Name , being duly sworn, do depose and certify that I am the Chief of Staff/Program Director at:
Name of Facility:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
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:

MonthDayYear
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
Should be Empty:

Public Health: Verification Of Residency Training Form