THE UNIVERSITY OF TEXAS MEDICAL BRANCH
HOUSE STAFF WORK AGREEMENT
NAME OF HOUSE STAFF

On the recommendation of, Program Director of the Sample Program residency/fellowship, The University of Texas Medical Branch at Galveston (UTMB) is pleased to offer you a position as resident/fellow at the postgraduate year - level, hereinafter referred to as PGY - ___ subject to the following terms and conditions:

1. The period of your appointment as PGY- ___ in this program will begin on ___/___/____ and end on___/___/____. The appointment is contingent on confirmation of your graduation from medical school, satisfaction of state licensure requirements, and the satisfaction of requirements for a J\ visa, if applicable. More detailed appointment information including institutional orientation, licensure/institutional permits, DEA registration, and "moonlighting" will be found in Section I of the "UTMB Hospitals--General Information for House Staff." and in Appendix 2.

2. Subject to your satisfactory participation in the residency program during the term of this Agreement, you will receive salary and benefits as may be established by UTMB for its house staff. As a house officer at UTMB, your salary is subject to all deductions required by state and federal law and such other deductions as you may authorize. More detailed salary and benefit information will be found in Section II of the "UTMB Hospitals--General Information for House Staff' and in Appendix 2.

3. As a house officer at UTMB, you will be expected to perform such duties and responsibilities as may be assigned to you and use your best efforts to provide safe, effective, and compassionate patient care. Your performance will be subject to all rules and regulations established by the Board of Regents of The University of Texas System, local rules and regulations contained in The University of Texas Medical Branch at Galveston "Handbook of Operating Procedures" and, for your specific residency program, the applicable requirements of the Essentials of Approved Residencies, as promulgated by the Accreditation Council for Graduate Medical Education (ACGME). You agree to be subject to the position description and basic responsibilities of a resident for which UTMB will provide an opportunity in APPENDIX IA & 1B of the "UTMB Hospitals--General Information for House Staff."

4. Appointment as a house officer at UTMB is for one year. You will be notified at least four months prior to the conclusion of this appointment (Item #1, Page I) if the faculty of your program does not intend to offer an appointment to you for the following year. This does not apply if you are in the last year of training for your program. If non-renewal of contract occurs within four months prior to end of this agreement, you will be provided with as much written notice of the intent not to renew as circumstanced reasonably allow. You agree that you will notify your program director at least four months prior to conclusion of this appointment if you do not plan to continue in the residency program after completion of the current level of appointment.

5. Your performance as a PGY- ___ will be reviewed and electronically evaluated by the faculty of your program on a quarterly basis in addition to other formal evaluations. You agree that you will be dismissed from the program during the term of this Agreement upon the determination by the faculty that your level of performance or professionalism does not meet the standards of the program and is unsatisfactory. Such dismissal shall be in accordance with the Regents rules and UTMB procedures. More detailed information concerning House Staff Due Process, Appeal and Grievance policies and procedures are found in Section III of the "UTMB Hospitals--General Information for House Staff."

6. In the event any provision(s) of this Agreement is (are) held invalid, the remainder of this Agreement shall not be affected by such invalidity. Please indicate your acceptance of the position as PGY - ___ in the Sample Program residency/fellowship program and the terms and conditions set forth above by signing in the space indicated below and returning the signed Agreement to the UTMB House Staff Office in the enclosed envelope. Your signature also indicates that you have read, understand, and agree to the requirements contained in the "UTMB Hospitals-General Information for House Staff' which has been provided to you.

Signature of Program Director __________________
Signature of House Officer __________________

NAME __________________
Sample Program Residency Program
Social Security # 000-00-0000
Date Accepted (must be filled in)

Original: House Staff Office
Copy: Program Director
Copy: House Staff Officer

Approved by the Graduate Medical Education Advisory Committee