Monitoring Report Updates

Connecticut Conrad 30 / J-1 Visa Waiver Program
Monitoring Report Updates

This form is to be filled out accurately and submitted to the Connecticut Department of Public Health annually (every year) of the 3 required years of service of the J-1 Physician. To provide information beyond four work sites, please submit a new form with the additional sites.
Date when Service Began:

MonthDayYear
month and (yyyy)
Report 2 and (yyyy)
Report 3 month and (yyyy)
J-1 Physician Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
This section is required to complete only if there have been changes to this information since the physician's application was submitted to CT DPH
Employer Name
(If different from the practice site name)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
This section is required to complete only if there have been changes to this information since the physician's application was submitted to the CT DPH.
Practice Site Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HPSA ID
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Area of Medicine
Practice Setting
YesNo
If no, Please provide a separate explanation
YesNo

If Yes, please list

Number of hours per week J-1 physician provided direct patient care during this reporting period:
Number of days J-1 physician was absent due to leave of absence in excess† of accrued paid time off:
Please provide a separate explanation of the excess break in service
Number of unduplicated patients during this reporting period (NOT number of patient visits):
Total number of patients seen during this reporting period (number of patient visits):

Patient breakdown by primary payer source for this reporting period: Site #1

Patient breakdown by primary payer source for this reporting period: Site #2

Patient breakdown by primary payer source for this reporting period: Site #3

Patient breakdown by primary payer source for this reporting period: Site #4

I hereby certify that I provided medical care services as described in this report and that all information contained in this report is true to the best of my knowledge and belief.

Signature
Date

MonthDayYear
I hereby certify that the aforementioned physician provided medical care services as described in this report and that all information contained in this report is true to the best of my knowledge and belief.
Employer Signatory
(Type/Print Name)
Title
____________________________
Signature of Employer
Date

MonthDayYear
Should be Empty: