Get Verification Of Residency

This guide provides clear instructions on how to complete the Verification Of Residency form online. It aims to simplify the process, ensuring that users understand each part of the form they need to fill out for residency training verification.

Follow the steps to accurately complete your Verification Of Residency form.

1. Press the ‘Get Form’ button to obtain the Verification Of Residency form and open it in your preferred editor.
2. In the first section, input your full name and date of birth as the applicant. Ensure that this information is accurate, as it will be used for identification purposes.
3. Next, the Chief of Staff or Program Director will need to verify residency training. They should enter the name of the facility where the residency was completed.
4. Then, indicate the dates of participation in the form by specifying the start and end dates in the format (month/day/year). This section helps establish the duration of the residency.
5. In the section regarding the specialty of the residency training, clearly state the field in which the training was completed.
6. Provide details about the level(s) of residency completed (e.g., PGY1, PGY2) to reflect the applicant's advancement through the program.
7. Indicate whether the residency training program was accredited at the time of training by marking 'YES' or 'NO' in the appropriate box.
8. Answer whether the individual satisfactorily completed the residency by selecting 'YES' or 'NO'. If 'NO', further details may need to be provided.
9. Respond to the questions regarding probation, discipline, and any limitations that may have been placed on the individual due to academic or disciplinary issues. Select 'YES' or 'NO' for each.
10. If complications are noted from questions 6 to 9, provide additional details or attach related documents to further explain these issues.
11. The Chief of Staff or Program Director must certify the information by signing the form, including their printed name, title, facility name, address, telephone number, and email address.
12. Finally, ensure the form is submitted directly to the Connecticut Department of Public Health by the indicated methods, such as mailing or faxing.

Complete your Verification Of Residency online today to ensure a smooth application process.