Request for CAMC Rotation
This form should be completed by the visiting resident requesting a rotation at Charleston Area Medical Center.
Visiting Resident Information
Enter your personal information.
Enter your full name & credentials (i.e. John Doe, M.D.)
Enter your current program level of training (i.e. PGL1).
Enter you email address.
Enter your phone number.
Enter your mailing address. (i.e. 3100 MacCorkle Avenue, SE Charleston, WV 25304)
Your program must email a letter indicating that they agree to the rotation, dates requested by yourself in this form, and that you are currently in good standing to gme@vandaliahealth.org before a rotation agreement will be executed. By checking the, 'I understand' box below you understand that the letter must be received before an agreement for you rotation will be executed.
I understand.
Before your rotation request will be sent to the CAMC program director for approval, you must upload a copy of your current CV.
Before your rotation request will be sent to the CAMC program director for approval, you must upload a copy of the goals and objectives for the rotation requested.
Visiting Resident's Sponsoring Institution Information
Enter information pertaining to your sponsoring institution.
Enter the official business name of your Sponsoring Institution.
Your Sponsoring Institution's Mailing Address
Visiting Resident's Program Infomation
Enter information pertaining to your current training program.
Enter the first name of your program director.
Enter the last name of your program director.
Enter the credentials of your program director.
Enter the email address of your program director.
Enter your program director's telephone number.
Enter the full name of your program coordinator/institutional representative that will assist in executing a rotation agreement.
Enter the email address of your program coordinator/institutional representative that will assist in executing a rotation agreement.
Enter the telephone number of your program coordinator/institutional representative that will assist in executing a rotation agreement.
Enter the full name of your DIO (Designated Institutional Official)L
Enter the email address of your DIO (Designated Institutional Official)L
CAMC Program Information
In which program are you requesting to complete a rotation?
Please select...
Cardiovascular Disease
Emergency Medicine
Family Medicine
Internal Medicine
Internal Medicine and Psychiatry
Gastroenterology
Greenbrier Valley Medical Center-Family Medicine
Greenbrier Valley Medical Center- Osteopathic Neuromusculoskeletal Medicine
Hematology and Medical Oncology
Interventional Cardiology
Pulmonary Critical Care Medicine
Neurology
Obstetrics and Gynecology
Pediatrics
Psychiatry
General Surgery
Pharmacy
Urology
Vascular Surgery
Participating Site of CAMC Program
Charleston Area Medical Center, Inc.
Participating Site Mailing Address Line 1:
3110 MacCorkle Avenue, SE
Participating Site Mailing Address Line 2:
Office of Graduate Medical Education, Room 2041
Participating Site Mailing Address Line 3:
Charleston, WV 25304
CAMC Program Director's First Name
CAMC Program Director's Last Name
CAMC Program Director's Credentials (i.e. MD, DO, MBBS, MHA, MPH)
Requested Rotation and Dates
Enter the name of the rotation you would like to complete and the dates you would like to request to schedule the rotation.
Enter the date you would like your rotation to begin using the following format: Month(word), dd, yyyy example, September 31, 2024
Enter the date you would like your rotation to end using the following format: Month(word), dd, yyyy example, September 31, 2024
Contact Information
