House Officer Request Form

Request to Hire a House Officer (New & Annual Renewals)For Programs beginning June/July _______Program Title: _________________________________________________Faculty Sponsor: _________________________________________________Department: □ DOCS □ MBS □ PHP □ VTHPosition:□ Internship □ ResidencyWill this be a VIRMP/MATCH listing? □ Yes □ NoIf yes, has a current advertisement been forwarded to CVM – Human Resources**?□ Yes □ No**If not, please attach a job description to this request to initiate Universityrecruitment.How many positions for this program are you requesting ______Does filling this position increase the number of house officers in this section beyondprevious numbers? □ Yes □ NoIf this position is filled, how many house officers will be in this program?_________Are there enough mentors to provide adequate training?□ Yes □ NoSource of Funding: □ State □ Vet Practice Plan (VPP) □ Other*Account number _________________________*If “Other”, please describe the source and answer the following questions.Source: ___________________________________________________________________________________________________________________________________________________________________________________- Is this a new funding source**? □ Yes □ No- Does this funding source restrictselection of the candidate hired?□ Yes** □ No**If “yes”, please describe the selection process:____________________________________________________________________________________________________________________________________________________________________________________

Please describe any changes to the program (deployment, duration, mentors,selection process, research requirements, etc) and justify:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Assessment of Impact on other Programs:- Will hiring this house officer have a significant □ Yes □ Noimpact on other CVM programs**?- Has the impact of this hire been discussed and is the hiresupported by other programs that may be impacted?□ Yes □ No**If yes, please describe the impact:_____________________________________________________________________________________________________________________________________________________________Department Head Approval:_______________________________Signature_____________________DateFCHOP Approval_______________________________FCHOP Chair signature______________________DateForm approved by FCHOP email vote August 2004modified 08/09/05modified 03/01/06modified 11/15/10