Institutional Policies

This page is designed to provide residents/fellows (trainees) the most up-to-date information on ACGME institutional policy and procedures, leave policies and procedures, and administrative policies and procedures.

Each program's policy manual must reference the institution manual and contain policies and procedures specific to the program. Some programs may have policies that are more rigid than the institution manual, in which case the program policy would be followed. Should a policy in a program manual conflict with the institution manual, the institution manual takes precedence.

Questions? Please email

Administrators please access a full list of policies from the GME Resource page.

Classification & Appointment Policy

Policy Statement

Primary Paid Appointments

All GME trainees must have a primary paid appointment in one of the following classifications, with the exception of those listed in the Without Salary Appointment Policy.


  • 9556 Medical Resident
  • 9559 Medical Resident – Graduate Program
  • 9582 NIH NRSA Medical Resident
  • 9583 NIH NRSA Medical Resident – Graduate Program


  • 9555 Medical Fellow
  • 9554 Medical Fellow – Graduate Program
  • 9568 NIH NRSA Medical Fellow
  • 9569 NIH NRSA Medical Fellow – Graduate Program

Secondary Without Salary Appointments

Trainees in accredited (Medicare eligible) training programs may not hold a secondary appointment at the University of Minnesota or University of Minnesota Physicians.

Trainees in non-accredited (non-Medicare eligible) training programs may hold a secondary appointment at the University of Minnesota or University of Minnesota Physicians.

Reason for Policy

To clarify the appropriate classification and appointment types for residents/fellows (trainees).

Related Information

NIH NRSA Training Grant Policy 


July 25, 2017: Amended to clarify the policy for trainees in non-accredited programs.


Clinical and Educational Work Hours Policy

Policy Statement 

The following policy applies to all Graduate Medical Education training programs sponsored by the University of Minnesota Medical School, both ACGME-accredited and non-accredited, and to all Graduate Medical Education trainees when assigned to any other institution or clinical site as part of their training program.

All programs are required to adhere to and monitor compliance of their trainees with the ACGME clinical and educational work hours standards as outlined in the ACGME Common Program Requirements. Training programs must also follow program-specific guidelines as outlined by their individual Review Committees. The sponsoring institution monitors training program adherence to the clinical and educational work hour requirements.

Management of clinical and educational work hours is a shared responsibility of programs and trainees.  The trainees must adhere to the policy and report violations. The program must structure clinical activities to adhere to, monitor and enforce compliance with the requirements. The institution must provide oversight to the programs and address non-compliance.

Reason for Policy 

The purpose of this policy is to define clinical and educational work hour requirements for Graduate Medical Education trainees, define oversight and monitoring for compliance with the regulations, and define the responsibilities of the trainees, the programs, and the sponsoring institution. 


Clinical and Educational Work Hours 

Time spent at the worksite performing clinical and/or academic activities required by the trainee’s GME training program, including: 

    • Patient care activities, both inpatient and ambulatory, whether scheduled or not. 
    • Administrative activities that are related to patient care. 
    • In-hospital “on call”, regardless of what the trainee activities are during such periods. 
    • Scheduled academic activities. 
    • Time spent on direct patient care activities and in-hospital during home call.
    • Time spent moonlighting, if allowed.

Trainee Responsibilities

Trainees are responsible for adhering to the schedule created by their programs to provide both educational and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities. Trainees have a personal role in accurately reporting their clinical and educational work hours. Trainees that are at risk of violating work hour rules have an obligation to inform program leadership so that coverage can be arranged to avoid violation.

Trainees are required to report the following work activities and all work hour violations to their program leadership for review and process improvement.

  • Patient care:

    • Inpatient and outpatient care occurring at the hospital or while at home.
    • Administrative duties related to patient care occurring at the hospital or while at home.
    • Electronic Medical Record (EMR) note writing, preparation of discharge summaries, phone calls related to patient care, while at home or at the training site.
    • The provision for transfer of patient care and sign-outs.
    • Time spent in-house during call activities.
  • Education/Academic:

    • Scheduled academic activities such as conferences or unique educational events.
    • Research.
    • Time spent at academic conferences and meetings when attendance is required by the program, or when the trainee is acting as a representative of the program. Only actual meeting time counts towards work hours.
    • Work hours spent on activities that are required by the accreditation standards or that are accepted practice in training programs.
  • The following activities are excluded from work hour reporting:

    • Academic preparation time.
    • Travel and non-conference time when at a conference or meeting.

Concerns about continuous work hour violations not adequately addressed by their program can be reported to the Designated Institutional Official at Anonymous reporting of work hour violations can occur via a Qualtrics form. Trainees may also report violations directly to the ACGME.

Program Responsibilities

Programs are responsible for knowing the clinical and educational work hours requirements set forth in the ACGME Common Program Requirements and in their program-specific requirements. 

    • Programs must design an effective program structure that is configured to provide trainees with educational and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities, within the bounds of ACGME requirements. 
    • Each program is required to have a written clinical and educational work hours policy consistent with this Institutional Policy. Specific night float requirements should be articulated in this policy as well as any exemptions if they are approved by the Review Committee.
    • The program's clinical and educational work hours policy and trainee relief procedures must be communicated to all members of the faculty and trainee staff.
    • Programs must implement a system to monitor compliance with clinical and educational work hour requirements and outline the protocol in their Program Manual. 
    • Programs must report work hour violations to the GME office quarterly and articulate a process for addressing those violations.
    • Programs must provide alternative coverage for a trainee’s clinical responsibilities if the trainee is too fatigued to continue their assigned clinical responsibilities. 

Sponsoring Institution Responsibilities


    1. The Sponsoring Institution must oversee clinical and educational work hours across all programs and address areas of non-compliance in a timely manner. The Graduate Medical Education office will review work hour violations as reported by programs quarterly and partner with programs to address non-compliance or concerning trends.
    2. The Sponsoring Institution must oversee systems of care, learning and working environments, and education programming that facilitate fatigue mitigation for trainees. In partnership with training programs, the Sponsoring Institution must ensure safe, quiet and private sleep facilities and safe transportation options for trainees who may be too fatigued to safely return home.


November, 2019: Revised for consistency with ACGME Institutional Requirements and ACGME Common Program Requirements.

January 2003: Approved by Graduate Medical Education Committee


  1. Policy Implementation

    1. Program Implementation Timeline

      • January 1, 2020: Programs are expected to develop a program level policy and process to comply with the revised GME policy and list their program policy in their program manual.

      • January 31, 2020: Programs must communicate the new policy and monitoring process to their residents or fellows and implement their plan.

    2. Graduate Medical Education Implementation Timeline

      • April 1, 2020: GME Administration emails a quarterly survey to programs asking them to certify that quarterly work hours (for period 1/1/2020 - 3/31/2020) have been reviewed and that violations have been addressed.

      • April 30, 2020: Programs complete the survey by this date.

      • May 1, 2020 to mid May 2020: GME Administration analyzes and reviews program responses to the survey. GME prepares the data to present to the GMEC.

      • May, 2020 (4th Tuesday): GME Administration presents data to the GMEC and shares the data with the respective programs and departments.

  2. Policy Monitoring

    1. Program Policy Monitoring: Example Methods 

      • Send out a monthly survey to residents or fellows for all of their rotations (sample survey)

      • Send out a survey quarterly to track low risk rotations

      • Do biopsy monitoring of all learners for a particular time frame (sample biopsy form)

      • Do biopsy monitoring of learners only on high risk rotations

      • Use RMS to conduct daily monitoring of high risk rotations

    2. Graduate Medical Education Monitoring

    3. Oversight

      • GME will compare the quarterly hours attestation with the trainee surveys (Annual Program Evaluation and the ACGME Annual Resident Fellow Survey.) Discrepancies must be explained by the program.

  3. Reporting

    1. Trainee Reporting Survey

Resource List

Completion of Step 3 of the Appropriate Licensing Exam (USMLE, COMLEX)

Policy Statement

All trainees must provide their program with documentation of a passing score on the United States Medical Licensing Examination (USMLE) Step 3 or an equivalent examination that qualifies for medical licensure (e.g. Comprehensive Osteopathic Medical Licensing Examination-COMLEX) by January 1 of their PGY-2 year.

Trainees who do not notify their program of a passing score by January 1 of their PGY-2 year forfeit their continuing position in the training program and are subject to contract non-renewal.

Upon application to the program, trainees who transfer into a University program (PGY-3 and beyond) are required to provide documentation of a passing score on their examination. 

Refer to your Program Manual for additional program specific guidelines.

Reason for Policy

To ensure that residents/fellows (trainees) complete the required licensing examination within the timeframe outlined below so that upon graduation from their program they will have completed the preliminary requirements to practice medicine in the United States.


Program Responsibilities

Monitoring and compliance of these examinations is expected at the Department/Program level.

Related Information

Eligibility and Selection Policy

Federation of State Medical Boards: 

National Board of Osteopathic Medical Examiners: 


9/26/2017 - Reviewed and updated by the GMEC. Changes include removing reference to ACGME Institutional Requirement IV.A.2.c).(2).


Disability Accommodations Policy

Policy Statement

The Graduate Medical Education (GME) training programs provide reasonable accommodations to residents/fellows who have a documented disability (physical,learning, psychiatric, vision, hearing, or systemic) that may affect their ability to participate in training activities or meet program requirements.To be eligible for reasonable accommodations, residents/fellows must work with Disability Services. Disability Services is the University of Minnesota office that has responsibility to review disability documentation and recommend reasonable accommodations for employees and students with disabilities, including residents/fellows participating in a GME training program.

Disability Services assists residents/fellows in securing documentation of disability conditions, determines whether a trainee is covered under disability laws, and if so, works with the resident/fellow and the training program to fashion reasonable accommodations for the individual. Disability Services also provides information, referral and consultation. The Disability Services office is located in the McNamara Alumni Center,Suite 170, (612) 626-1333 (voice or TTY), email:

In order to successfully complete a residency or fellowship program, all residents/fellows must meet the essential requirements of their training program; residents/fellows with disabilities must be able to meet the essential requirements, with or without reasonable accommodations.

Related Information

Board of Regents Disability Services Policy



Discipline, Dismissal, Failure to Advance Policy & Procedure

Policy Statement

Trainees can be disciplined for both academic and non-academic reasons. Forms of discipline include, but are not limited to: warning, required compliance, probation, suspension, failure to advance, and dismissal. There are separate grounds and procedures for each type of discipline as outlined below.


Discipline/Dismissal for Academic Reasons


As students, GME trainees are required to maintain satisfactory academic performance. Academic performance that is below satisfactory is grounds for discipline and/or dismissal. Below satisfactory academic performance is defined as a failed rotation; relevant exam scores below program requirements; and/or marginal or unsatisfactory performance, as evidenced by faculty evaluations and other assessments, in the areas of clinical diagnosis and judgment, medical knowledge, technical abilities, interpretation of data, patient management, communication skills, interactions with patients and other healthcare professionals, professionalism, and/or motivation and initiative.

To maintain satisfactory academic performance, residents/fellows also must meet all eligibility requirements throughout the training program. Failure or inability to satisfy licensure, registration, fitness/availability for work, visa, immunization, or other program-specific eligibility requirements are grounds for dismissal or failure to advance in the program.


Before dismissing a trainee or failing to advance for academic reasons, the program must give the trainee: 

  • Notice of performance deficiencies;
  • An opportunity to remedy the deficiencies; and
  • Notice of the possibility of dismissal or failure to advance if the deficiencies are not corrected.

Trainees disciplined and/or dismissed for academic reasons may be able to grieve the action through the Conflict Resolution Process for Student Academic Complaints Policy. This grievance process is not intended as a substitute for the academic judgments of the faculty who have evaluated the performance of the trainee, but rather is based on a claimed violation of a rule, policy or established practice of the University or its programs.

Academic Probation

Trainees who demonstrate a pattern of unsatisfactory or marginal academic performance will undergo a probationary period. The purpose of probation is to give the residents/fellows specific notice of performance deficiencies and an opportunity to correct those deficiencies. The length of the probationary period may vary but it must be specified at the outset and be of sufficient duration to give the trainee a meaningful opportunity to remedy the identified performance problems. Depending on the trainee’s performance during probation, the possible outcomes of the probationary period are: removal from probation with a return to good academic standing; continued probation with new or remaining deficiencies cited; non-promotion to the next training level with further probationary training required;failure to advance in the program, or dismissal.

Discipline/Dismissal for Non-Academic Reasons


Grounds for discipline and/or dismissal of a trainee for non-academic reasons include, but are not limited to, the following: 

  • Failure to comply with the bylaws, policies, rules, or regulations of the University of Minnesota, affiliated hospital, medical staff, department, or with the terms and conditions of this document.
  • Commission by the trainee of an offense under federal, state, or local laws or ordinances which impacts upon the abilities of the trainee to appropriately perform his/her normal duties in the residency/fellowship program.
  • Conduct, which violates professional and/or ethical standards; disrupts the operations of the University, its departments, or affiliated hospitals; or disregards the rights or welfare of patients, visitors, students, hospital/clinical staff, or others involved in the training program.


Prior to the imposition of any discipline for non-academic reasons, including, but not limited to, written warnings, probation, suspension, or termination from the program, a trainee shall be afforded:

  • Clear and actual notice by the appropriate University or hospital representative of charges that may result in discipline, including where appropriate, the identification of persons who have made allegations against the trainee and the specific nature of the allegations; and,
  • An opportunity for the trainee to appear in person to respond to the allegations.
  • Following the appearance by the trainee, a determination should be made as to whether reasonable grounds exist to validate the proposed discipline. The determination as to whether discipline would be imposed will be made by the respective Medical School department head or his or her designee. A written statement of the discipline and the reasons for imposition, including specific charges, witnesses, and applicable evidence shall be presented to the trainee.

After the imposition of any discipline for non-academic reasons, a trainee may avail themselves of the following procedure:

  • If within thirty (30) calendar days following the effective date of the discipline, the trainee requests in writing to the Dean of the Medical School a hearing to challenge the discipline, a prompt hearing shall be scheduled. If the trainee fails to request a hearing within the thirty (30) day time period, his/her rights pursuant to this procedure shall be deemed to be waived.

    • The hearing panel shall be comprised of three persons not from the residency/fellowship program involved: a chief resident; a designee of the Dean of the University of Minnesota Medical School; and an individual recommended by the Chair of the Graduate Medical Education Committee. The panel will be named by the Dean of the Medical School or his or her designee and will elect its own chair. The hearing panel shall have the right to adopt, reject or modify the discipline that has been imposed.

At the hearing, a trainee shall have the following rights:

  • Right to have an advisor appear at the hearing. The advisor may be a faculty member, trainee, attorney, or any other person. The trainee must identify his or her advisor at least five (5) days prior to the hearing;
  • Right to hear all adverse evidence, present their  defense, present written evidence, call and cross-examine witnesses; and,
  • Right to examine the individual's residency/fellowship files prior to or at the hearing.
  • The proceedings of the hearing shall be recorded.
  • After the hearing, the panel members shall reach a decision by a simple majority vote based on the record at the hearing.
  • The residency/fellowship program must establish the appropriateness of the discipline by the weight of the evidence.
  • The panel shall notify the trainee in writing of its decision and provide the trainee with a statement of the reasons for the decision.

Although the discipline will be implemented on the effective date, the stipend of the trainee shall be continued until his or her thirty (30) day period of appeal expires, the hearing panel issues its written decision, or the termination date of the agreement, whichever occurs first.

The decision of the panel in these matters is final, subject to the right of the trainee to appeal the determination to the President's Student Behavior Review Panel. 

The University of Minnesota, an affiliated hospital, and the department of the trainee each has a right to impose immediate summary suspension upon a trainee if his or her alleged conduct is reasonably likely to threaten the safety or welfare of patients, visitors or hospital/clinical staff. In those cases, the trainee may avail he or she of the hearing procedures described above. The foregoing procedures shall constitute the sole and exclusive remedy by which a trainee may challenge the imposition of discipline based on non-academic reasons.

Failure to Advance

In instances where a trainee fails to advance, the University of Minnesota Medical School ensures that its ACGME accredited programs provide the trainee(s) with a written notice of intent not to advance a trainee(s) agreement no later than four months prior to the end of the trainee’s current program year. However, if the primary reason(s) for failure to advance occurs within the four months prior to the end of the program year, the University of Minnesota Medical School ensures that its ACGME-accredited programs provide the trainee(s) with as much written notice of the intent not to advance as the circumstances will reasonably allow, prior to the end of the program year.

Trainee(s) will be allowed to implement the institution’s grievance procedures if they have received a written notice of intent not to advance them in the program.


ECFMG Required J-1 Visa Holder Notification Policy

Policy Statement

Residents and fellows (trainees) who are sponsored by the Education Commission on Foreign Medical Graduates (ECFMG) as a J-1 visa holder must notify ECFMG whenever they are experiencing a qualifying required notification event such as; off-site rotations, leave of absences, physician resignation, dismissal, remediation, or an incident/allegation against them, or a J-2 dependent. Federal regulations require that ECFMG maintain up-to-date records on the locations, and activities of the exchange visitor physicians it sponsors. Failure to communicate a qualifying required notification event of a J-1 visa holder to ECFMG can result in premature expiration of the trainee’s DS-2019, which can cause major disruptions to training, or incompletion of program.

Required Notification Events

  1. Off-site rotations: ECFMG must be informed at least 30 days in advance of any proposed off-site rotation or elective that will be conducted at a location other than the approved “Sponsoring Institution” or a “Participating Site” for the training program as reported to and recognized by the ACGME, including international rotations.
  2. Leave of Absence: ECFMG must be informed in advance of any planned LOA including, but not necessarily limited to, medical, parental, or academic leave. Once notified of a planned LOA, ECFMG will review the plan to ensure that eligibility for J-1 visa sponsorship is not impacted and that sponsorship can be maintained for the full duration of the leave. Additional documentation may be requested upon review. Once ECFMG has fully evaluated the plan and any supporting documentation provided, ECFMG will follow-up with the exchange visitor physician and the Training Program Liaison (TPL) at the host institution. NOTE: ECFMG does not sponsor, or extend time for personal leaves of absence.
  3. Physician Resignation: When a J-1 physician resigns, ECFMG must amend a physician’s Student and Exchange Visitor Information System (SEVIS) record upon a physician’s resignation from his/her training program. Therefore, ECFMG must be informed immediately of a physician’s plans to leave his/her training program in advance of the program end date listed on Form DS-2019. Once notified of a resignation, ECFMG will adjust the individual’s SEVIS record to reflect the new program end date and an e-mail will be sent to the physician notifying him/her of the action taken by ECFMG. Exchange visitor physicians who resign are federally required to depart the United States within 30 days of an amended SEVIS end date. 
  4. Physician Dismissal: ECFMG is required to monitor the activities of the exchange visitor physicians it sponsors and to update the Student and Exchange Visitor Information System (SEVIS) if/when an exchange visitor physician is released from the approved training program and site of activity. Therefore, ECFMG must be informed immediately of any exchange visitor physician’s dismissal in advance of the originally-approved program end date listed on Form DS-2019 and/or prior to program completion. Once notified of a dismissal, ECFMG will adjust the individual’s SEVIS record to reflect the new program end date and an e-mail will be sent to the exchange visitor physician notifying him/her of the action taken by ECFMG. 
  5. Remediation: ECFMG requires notification of anyformalremedial action for a trainee,  
  6. Incident or Allegation: As an exchange visitor program sponsor, ECFMG must monitor the well-being of exchange visitor program participants and report incidents involving exchange visitor physicians and/or their accompanying J-2 dependent(s) to the U.S. Department of State (DoS). Therefore, ECFMG must be notified of any serious matter involving an exchange visitor physician or accompanying J-2 dependent. The DoS has indicated that any incident or event that impacts the health, safety, or welfare of J visa holders or that could bring the DoS exchange visitor program “notoriety or disrepute” is reportable. 


Program Responsibility 

The program and/or J-1 is required to report any qualifying notification event listed above to the GME office Training Program Liaison (TPL). The TPL will upload the form to the J-1 visa holders appointment profile within ECFMG.  

  • Up to date forms for each incident type can be located on the ECFMG website, linked here.

After the form is submitted, ECFMG may require additional information, or verification such as; 

  1. written confirmation from the J-1 that they will hold/held health insurance and will not/did not train outside their current approved training program during the time of leave

  2. letter from the program director (on letterhead) outlining the exact dates used for time extending the J-1’s programand break down of the allotment of time (vacation, sick leave, paid leave of absence, unpaid leave of absence);

  1. revised contract/offer letter with the new projected exact end date of the training program for the academic year in question.


Eligibility and Selection Policy and Procedure

Policy Statement



Prior to their program start date residency program applicants must provide their program with documentation of the following qualifications to be eligible for appointment:

  1. Graduation from a medical school that meets one of the following requirements: 

    1. Graduation from medical school in the United States or Canada and accredited by the Liaison Committee on Medical Education (LCME), OR

    2. Graduation from a college of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA), OR

    3. Graduation from a medical school outside of the United States or Canada meeting one of the following additional requirements:

      1. Holds a currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG), OR

      2. Holds a full and unrestricted license to practice medicine in Minnesota.

  2. Passing scores on Steps 1 and 2 (Clinical Knowledge) of the United States Medical Licensing Examination (USMLE) or an equivalent examination that qualifies for medical licensure (e.g., Comprehensive Osteopathic Medical Licensing Examination-COMLEX).

  3. Eligible for either a residency permit or a permanent medical license as granted by the Minnesota Board of Medical Practice.

  4. For those trainees entering a program after a Transitional or Preliminary PGY-1 year, a written or electronic verification of previous educational experiences and a summative evaluation of the resident performance addressing the six ACGME competencies.


In addition to the previous requirements listed under Residents, fellowship program applicants must also provide their program with documentation of the following qualifications to be eligible for appointment:

  1. Graduation from an appropriate ACGME residency program, or a Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency program located in Canada (Residents who temporarily suspend their residency training to take a subspecialty fellowship position do not have to provide a completion certificate); and

  2. A passing score on USMLE Step 3 or an equivalent examination that qualifies for medical licensure (e.g., Comprehensive Osteopathic Medical Licensing Examination-COMLEX); and

  3. A written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the trainee.

Fellowship program applicants who have not completed an ACGME residency program, or a Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency program located in Canada may be allowed under special circumstances, which require review and approval.  See “ACGME Fellow Eligibility Exceptions Guide” under Related Information.


  1. Programs select from among eligible applicants based on their educational preparedness, ability, aptitude, academic credentials, communication skills and personal qualities such as motivation and integrity. 

  2. The Medical School does not discriminate with regard to sex, race, color, creed, religion, national origin, age, marital status, disability, public assistance status, veteran’s status or sexual orientation

  3. The Medical School participates in the National Residency Matching Program (NRMP).  Each accredited residency/fellowship program that participates in the NRMP Match will abide by the rules and regulations of the NRMP.  Those programs using other Match programs will abide by their rules and regulations.

Trainee Transfers

In accordance with the ACGME’s Common Program Requirements prior to accepting a trainee from another residency or fellowship program the program director must obtain the following:

  1. Written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident or fellow.

  2. Proof that the transferring resident or fellow has passed the USMLE Step 3 or equivalent licensing examination (e.g. COMLEX) for PGY-3 residents or higher.

A program director must provide timely verification of residency education and summative performance evaluations for residents and fellows who leave the program prior to completion.

Reason for Policy

To outline specific qualifications required for eligibility and selection of residents/fellows (trainees) entering a University of Minnesota Medical School Graduate Medical Education training program.


Program Responsibilities: 

Monitoring and compliance of the eligibility requirements is expected at the Department/Program Level.


Evaluation Policy

Policy Statement

All University of Minnesota Medical School Graduate Medical Education training programs are required to use an electronic evaluation instrument (i.e. RMS, E*Value). In accordance with ACGME Common Program Requirements programs must follow the evaluation criteria outlined below.


Trainee Formative and Summative Evaluation

The faculty must evaluate trainee performance in a timely manner during each rotation or similar educational assignment and document this evaluation at completion of the assignment. A trainee’s competence in patient care, medical knowledge, practice-based learning and improvement, attitudes, interpersonal relationships and communication skills, professionalism and systems-based practice must be evaluated.

The program must use multiple evaluators (i.e. faculty, peers, patients, self, other professional staff). Programs must evaluate their residents/fellows on an ongoing basis to assure adequate progress commensurate with the trainee's level of education and experience. Overall reviews of the trainee's progress will be conducted at least semi-annually by program faculty with responsibility for monitoring the overall academic progress of all residents/fellows in the training program. Trainees who make satisfactory progress as determined by the program director will be promoted and given increased graded responsibilities, please see Resident/Fellow Standing and Promotion Policy.

The program director must provide a final evaluation for each trainee who completes the

program. This evaluation must include a review of the trainee’s performance during the final period of education, and should verify that the trainee has demonstrated sufficient professional ability to practice competently and independently. We encourage programs to use our Standard Verification of Training Form for this purpose. The final evaluation must be part of the trainee’s permanent record. Written evaluations must be available to the residents/fellows to enable them to assess their progress and improve performance.  

Faculty Evaluation

The program must evaluate faculty performance as it relates to the educational program at least annually. The evaluations should include a review of the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism and scholarly activities.

This evaluation must include annual written confidential evaluations by the trainees. Programs are encouraged to employ one of the following methods to ensure confidentiality of faculty evaluations:

GME Administration– work with GME to develop a process whereby the program sends faculty evaluations to GME Administration. GME will collate and return a summary report back to the program to disseminate back to faculty.

Program Director– develop a process whereby the faculty evaluations are sent to the Program Director who will collate and return a summary report back to the faculty members.

Division Director– develop a process whereby the faculty evaluations are sent to the Division Director who will collate the data and use the summary data for faculty reviews and consultation with the program director.

Department Chair– develop a process whereby the faculty evaluations are sent to the Department Chair who will collate and return a summary report back to the program.

Program Evaluation

The program must document formal, systematic evaluation of the curriculum at least annually, the program must monitor and track each of the following areas:

  1. Trainee performance;

  2. Faculty development;

  3. Graduate performance, including performance of program graduates on the certification examination and;

  4. Program quality, specifically:

    1. trainees and faculty must have the opportunity to evaluate the program confidentially and in written at least annually and;

    2. the program must use the results of the trainees’ assessments of the program together with other program evaluation results to improve the program.

Representative program personnel (i.e., at least the program director, representative faculty, and one trainees) must be organized to review program goals and objectives, and the effectiveness with which they are achieved. This group must conduct a formal documented meeting at least annually for this purpose.

If deficiencies are found, the program should prepare a written plan of action to document initiatives to improve performance in the areas listed. The action plan should be reviewed and approved by the teaching faculty and documented in the meeting minutes.


Health Insurance Requirement for Health Sciences Students

The GME office abides by the Academic Health Center Policy for health insurance requirements

Resident/Fellow Fitness for Duty Policy

Policy Statement

Trainees are required to report to work physically and mentally capable of safely performing the functions of their job.  Trainees must not report to work if they are impaired for any reason.  Trainees must not consume alcohol or any controlled substance while on call, including “at home call.”  Trainees must self-regulate their use of prescribed or over the counter medications to ensure these medications do not cause impairment.  Trainees must manage their sleep to avoid excessive fatigue. Programs have a responsibility to remove trainees from patient care activities if the trainee’s impairment poses a threat to patient safety.

Reason for Policy

The purpose of this policy is to define expected trainee conduct as it relates to fitness for duty, to provide guidance and direction on how to proceed when confronted with a potentially impaired trainee, and to help trainees in obtaining assistance when needed.

We are committed to providing healthy, safe, and supportive training environments for all trainees, as well as safe, high-quality care for patients.  Trainees practicing while impaired can have serious adverse effects on patient safety, and negative impacts on their own performance and safety as well as that of others in the workplace.



Responsibility to Report: Anyone who is aware of signs of impairment displayed by a trainee has an obligation to make a report to the trainee’s Program Director or supervisor on duty.

Self-Reporting: Any trainee who believes they themselves may be impaired is required to contact their Program Director or supervisor on duty to report the situation. If a trainee is approached by a co-worker or patient who is concerned the trainee may be impaired due to fatigue or any other reason, the trainee has a professional responsibility to contact their Program Director to inform them of the concern.


  1. The Program Director shall obtain as much detailed information as possible at the time of the report from sources including the trainee and the reporter. Based on the information gathered, the Program Director will determine whether additional review is needed.

  2. If indicated and depending upon the circumstances, additional review may be carried out by the Program Director, by a committee, by an outside consultant, or by some other appropriate person(s) or agency. The trainee and the reporter, as well as other appropriate sources, should be interviewed as a part of the review.

  3. The highest priority is patient safety.  If the Program Director cannot ensure the trainee’s ability to safely care for patients, the trainee should be immediately removed from duty and placed on paid administrative leave pending further review.

  4. The Program Director shall notify the Associate Dean for GME of the trainee fitness for duty review.

Results of the Review

Based on the results of the inquiry, the Program Director may choose one of the following determinations:

  1. No Impairment

    1. Trainee, Associate Dean for GME, and other relevant parties (if applicable) shall be informed of the outcome of the review.

    2. A written report of the review and its outcome shall be maintained by the program separate from the trainee’s file. This documentation may be a relevant source of information in any future reviews.

  2. Evidence of Impairment

    1. Trainee, Associate Dean for GME, and other relevant parties shall be informed of the outcome of the review.

    2. If required by law, an immediate report shall be made to the Minnesota Board of Medical Practice or other organizations.

    3. Further action(s) may include:

      1. Referral to an appropriate resource (such as the Resident Assistance Program, Health Professionals Service Program, Physicians Serving Physicians, or relevant rehabilitation or treatment programs)

      2. Restriction of privileges based on the impairment

      3. Discipline or dismissal, pursuant to the GME Discipline, Dismissal, Non-Renewal Policy & Procedure

    4. A written report of the review and its outcome shall be kept in the trainee’s file.

    5. Except in the case of dismissal, the Program Director and the trainee shall draft a written plan to address the impairment. It is advised that this be done in consultation with the Associate Dean for GME and the Office of the General Counsel. A signed copy of the plan shall be kept in the trainee’s file.  The Program Director and trainee shall periodically review the impairment and the plan, and document such review in the trainee’s file.


Due to the safety-sensitive nature of their work, trainees must manage their off-duty exposure to substances that may cause impairment, including prescription medications. Because these substances affect each person differently, there are no universally applicable standards.  In the case of alcohol, we reference U.S. FAA regulations for airline pilots as a guideline. These regulations prohibit pilots from operating an aircraft within 8 hours of the consumption of any alcohol, or while having a blood alcohol content of 0.04% or greater regardless of length of time since last consumption [FAR 91.17]. The institution expects trainees to refrain from alcohol consumption within 8 hours of reporting for duty or being on call.


An impaired resident/fellow (trainee) is defined as any trainee who is unable to safely care for patients, perform duties normally expected of a trainee physician, or engage in peer interaction necessary for patient care for any reason, including but not limited to: personal stress; fatigue; medical condition (including physical disability or mental illness); use of alcohol or controlled substances, including drugs prescribed by a physician; or use of over the counter medication.

Fit for duty is defined as being physically and mentally capable of safely performing the functions of one’s job.  Fitness for duty includes being free of alcohol and drugs that have not been legitimately prescribed, and being free from impairment that affects job functioning for any reason, including but not limited to personal stress, fatigue, use of drugs prescribed by a physician, or use of over the counter medication.

GME Leave Policy

Policy Statement

Residents and fellows (trainees) may request time away from their program by accessing the leaves outlined in this policy. The trainee must give notice, in writing, of intent to use a leave of absence to their program director at least eight (8) weeks in advance, except under unusual circumstances. A leave of absence is only available to those who request the leave in compliance with program policy and receive approval from the program. Questions regarding leave must be directed to the program director and program coordinator. Refer to your program manual for specific program expectations.

Each program is responsible for maintaining accurate records of the amount of leave time taken by each trainee. The American Board of Medical Specialties requirements must be reviewed by the program director and trainee to ensure that the trainee understands if their training will be extended.

The program manual for the residency or fellowship will have specific policies and procedures that apply to the trainees in compliance with the program board requirements.

Unused vacation days are not paid out at the end of the academic year.

Trainees on unpaid leaves of absences must provide the Office of Student Health Benefits with payment information for the employee share of benefits so they can continue to receive medical and dental benefits during the unpaid leave

Reason for Policy

Resident and fellow (trainee) health is important. The purpose of this policy is to establish guidelines for leaves in accordance with federal laws, state laws and & institutional policies.

Program Responsibility:

The program is responsible for defining and communicating their program leave policies and processes, in their program manual.

Programs are responsible for tracking time off for all leaves. They must ensure that specialty board requirements are met prior to trainees graduation from the program. They must inform the trainee if their leave will extend training.

Programs are responsible for notifying all stakeholders of a trainee leave of absence.The program must fill out the GME Leave of Absence summary and email it to the appropriate stakeholders listed on the summary.

Programs must work with their trainees to report all leaves in the Residency Management Suite (RMS) according to instructions received by MMCGME Services.  Programs must also forward documentation to MMCGME Services for leaves that extend the trainees time in the program.

Leaves of absence for trainees on J-1 visas must be approved by ECFMG. Programs are required to submit the ECFMG Required Notification of LOA form to the GME Office before a trainee who is on a J-1 visa is planning to take a leave of absence. The form will then be submitted by the Training Program Liaison (TPL) to ECFMG for approval. ECFMG will email the TPL and the trainee when a determination is made about the leave. The approval will be forwarded to the program so they are able to move forward with processing the leave. For more information see the GME Policy: ECFMG Required J-1 Visa Notification Policy

If the leave extends training, financial support for the additional training time must be determined by the program when arrangements are made for the leave.

See your program manual for specific departmental policies and procedures

Types of Leave

Bereavement Leave:

Bereavement Leave is available to support trainees experiencing a significant personal loss due to the death of an immediate family member, other family members, and colleagues. Bereavement Leave will allow you to:

  • Attend funeral services, ceremonies, and interment
  • Make necessary arrangements, including travel if necessary
  • Serve as pallbearers

Immediate Family:

Granted up to three work days paid bereavement leave. Up to two additional work days of paid leave may be granted at the discretion of the program director upon consideration of the funeral location (local or long distance), cultural expectations, rituals, ceremonies, etc. and other pertinent factors. Leave will normally be used during the seven-calendar-day period immediately following the death.         

Death of other family members:

Granted up to one work day paid bereavement leave. Leave will normally be used during the seven-calendar-day period immediately following the death.

Death of a colleague:

Granted reasonable paid (typically less than one day) bereavement leave time away from work to attend the funeral or service. Leave is subject to the needs of the program as determined by the program director and the department or administrative unit head. 

Extended Absence:

Absences not covered by paid bereavement leave provisions are accommodated by the use of available vacation time and/or unpaid personal leave at the discretion of the program director. To be supportive of trainees who are experiencing a significant personal loss, the University strongly encourages flexibility in granting requests for additional paid (as available and appropriate) and unpaid leave time beyond the paid bereavement leave provisions.

Family Medical Leave Act (FMLA):

The Family Medical Leave Act, or FMLA is a federal law that allows trainees, who are eligible, up to 12 weeks of protected leave per academic year. Trainees must consult with their program to determine if they are eligible.

With the proper medical documentation and supervisor approval, FMLA can be used for:

  1. Your own serious health condition
  2. The serious health condition of an immediate family member
  3. Caring for a newborn or newly-placed adopted child or foster child
  4. The urgent need of an immediate family member who is on active duty in the military services

Leave shall not exceed 12 weeks in any 12-month period.  The 12-month period is based on an academic year (07/01-06/30).  The trainee may be eligible for Short Term and Long Term Disability benefits.  Department Human Resources staff will determine FMLA eligibility and will provide the trainee with the appropriate paperwork.

Holiday Leave:

Holiday leave is dependent on the requirements of the rotation to which the trainee is assigned. The educational requirements and the 24-hour operational needs of the hospital are taken into consideration when scheduling holiday time off.

Trainees are not eligible to receive an annual University of Minnesota issued personal holiday.

Military, Court Appearance, or Civic Duty Leave

Trainees may be absent from work for military leave, jury duty, appearance in court, and voting or serving as an election judge in federal or state elections as outlined in this policy. Trainees must notify the program as soon as they are called to active military duty.  It is incumbent upon the program director to notify both the individual RRC and the Board of this change in status.

Military Leave:

Military leave, whether voluntary or involuntary, is taken for service including activities such as training, active duty, full-time National Guard duty, and fitness for military duty examinations.

Military leave applies to trainees who are members of the following: the National Guard and Air National Guard; an armed forces branch of the United States military, regular or reserve, (Army, Navy, Air Force, Marines, Coast Guard); commissioned corps of the Public Health Service; or any other category of persons designated by the President of the United States in time of war or national emergency.

Trainees are granted military leave in accordance with federal and state laws and regulations and University policy. Trainees are granted leave with pay, not exceeding 15 days in any calendar year, for required service in the National Guard or any of the armed services reserve forces. Additional leave without pay is granted for the duration provided within federal and state laws and regulations.

Trainees are entitled to resume University service following their military leave. Trainees who are re-employed after a military leave of 30 to 180 days may not be discharged without cause for six months after the date of re-employment. Trainees who are re-employed after a military leave of 181 days or more may not be discharged without cause for one year after the date of re-employment.

For military family leaves associated with a trainees immediate family member being on or receiving a federal call to active duty status in support of a contingency operation or having a serious injury or illness incurred while on active duty, refer to the FMLA Policy.

Appearance in Court

Trainees are granted paid leave when testifying before a court or a legislative committee on matters concerning federal or state government, the University, or when called to testify as an expert, so long as their testimony or consultation is unpaid.  Trainees who are victims of certain crimes are provided unpaid personal leave in accordance with, and as defined by law.

Jury Duty

Trainees are granted paid leave when serving on a jury, including the jury selection process. When the jury is recessed, the trainee is expected to be working during any normal work time.

Voting and Election Judge Leave

Trainees are eligible for a paid leave of absence to vote in any state-held general election, primary special election, and special primary for the time necessary to appear at the trainees polling place, cast a ballot, and return to work on the day of that election. Paid leaves to vote cover only those hours the trainee is regularly scheduled to work and are provided to only those trainees who specifically request time off to vote.

Trainees are eligible for a paid leave of absence to serve as a precinct election judge. To be eligible, a trainee, at least 20 days in advance, must provide a written leave request accompanied by certification from the appointing authority stating the hours of service.

Parental Leave:

Parental leave provided by this policy is available to a trainee on 50% appointment or greater and who is becoming a parent through birth, adoption, gestational surrogacy or to a trainee who is a gestational carrier.

Upon request, eligible trainees may take up to six weeks paid parental leave. The parental leave will begin at a time requested by the trainee, but not more than two weeks prior to the due date or adoption event, and no later than 13 weeks - after the birth or adoption event, or longer at the discretion of the program. In the case where the child must remain in the hospital longer than the birth parent, the leave must begin no later than 13 weeks after the child leaves the hospital. Parental leave is a paid benefit for all trainees, which will not be deducted from other paid time away. This leave must be consecutive and without interruption, and must be taken during the term of appointment. 

During parental leave, medical coverage will continue to be available for the trainee and any dependents who are enrolled under the Office of Student Health Benefits Resident, Fellow, and Intern plan. While on parental leave, the continued coverage will be provided on the same basis as available to the trainee during the course of employment. 

While on unpaid leave not covered by FMLA, the continued coverage will be available at the trainee's expense. The Office of Student Health Benefits will provide trainees with information about benefits and premiums due while on leave. If premiums are due, the OSHB will request the trainee to complete a payment authorization form to pay these dues to ensure continuous coverage.

Trainees may be eligible for other leaves that occur prior to or after parental leave under other applicable leave policies. In all cases, FMLA runs concurrently with paid parental leave and other applicable paid leaves.

Note: The first two weeks of the paid parental leave covers the required fourteen day wait period before  the parent who gave birth may be eligible to receive short-term disability benefits. See Short Term Disability Policy at:

Trainees who give birth may also receive the short-term disability benefit while on a paid parental leave. 

Personal Leave:

Personal Leave is for trainees who need time away from work to attend to matters that affect their lives, that are unrelated to their training in graduate medical education, and that significantly interfere with their ability to meet their work responsibilities.

Examples of personal leave may include, but are not limited to:

  • Your own serious health condition (for trainees who are not eligible for FMLA)

  • Extension beyond FMLA period of 12 weeks per academic year

  • The serious health condition of an immediate family member (for trainees who are not eligible for FMLA)

  • Caring for a newborn or newly-placed adopted child or foster child (for trainees who are not eligible for FMLA)

  • The urgent need of an immediate family member who is on active duty in the military service (for trainees who are not eligible for FMLA.

Professional Leave:

The Institution supports a culture of excellence and is committed to providing its trainees with opportunities to participate in professional development, education, and training activities. Programs may provide time off for their trainees that is not deducted from their paid time away allocation.

Examples of professional leave may include, but are not limited to:

  • Academic
  • Continuing Medical Education (CME)
  • Interviewing
  • Professional Conference Attendance/Presentation

Vacation Leave:

Vacation leave is paid time away from work for you to use for your personal activities and to create a healthy balance between your work and personal life.

Availability and Requesting Vacation Leave

The amount of vacation leave available to you, and the guidelines for using vacation leave varies by program. Refer to your program manual for details.

Health Leave (Previous known as Sick Leave):

Health leave is time away from work to use to care for your own wellbeing or for the wellbeing of your dependent children or immediate family members.

Trainee Process: Availability of Leave and Requesting Health Leave

The amount of health leave available to you, and the guidelines for using health leave varies by program. Refer to your program manual for details.


Immediate Family Member

An immediate family member is described as; (1) The spouse or domestic partner, (2) the trainees: (a) biological, adoptive, step, or foster child or ward; (b) parent or parental equivalent; or (c) sibling, and (3) the trainees spouse’s or domestic partner’s: (a) biological, adoptive, step, or foster child or ward; (b) parent or parental equivalent; or (c) sibling.


Graduate Medical Education Professionals in Training who are classified as one of the paid or unpaid appointments at the University of Minnesota on the Classification & Appointment Policy, or the Without Salary Appointment Policy.

Related Information:


  • 8/25/2021: The GME Leave Policy was updated to remove outdated language around who is eligible for personal leaves. Previously, the J-1 visa did not support this kind of leave, this statement has now been removed. The ‘Program Responsibility’ section was moved to the top of the page under the section ‘Reason for Leave’, so the programs have clear visibility on what to do when a leave is requested. Added to the Program Responsibilities section was a clarifying statement on how programs should inform all stakeholders through the GME LOA Summary, and that all J-1 visa holders' leaves must be approved by ECFMG before the leave occurs when at all possible. The changes were approved by the GMEC on August 24, 2021.
  • 1/28/2020: Parental leave section was updated to state no later than 13 weeks after the birth or adoption event, or longer at the discretion of the program. The policy previously stated “no later than 7 weeks.” The GMEC also approved the section in parental leave that states, “Trainees may be eligible for other leaves that occur prior to or after parental leave under other applicable leave policies. In all cases, FMLA runs concurrently with paid parental leave and other applicable paid leaves.”
  • 9/24/2019: Parental leave section was added. The Graduate Medical Education Office mirrors the University of Minnesota’s Parental Leave Policy as much as possible for eligible trainees related to the birth, adoption, gestational surrogacy of children or to a trainee who is a gestational carrier in accordance with Minnesota statutes and the provisions of this policy.
  • 1/16/2018: Historically all of the Graduate Education Office Leave Policies have been individual policies. The policies above have been combined into one document, with the exception of the Parental Leave Policy. These policies have been updated to align with the University of Minnesota Human Resource policies.
  • Bereavement leave has been expanded to include death of other family members, colleagues and possible need for extended absence.
  • Jury Leave and Voting Leave have been combined into the Military Leave section of this policy. An appearance in the court section has been added to Military leave.
  • Vacation and Sick Leave have been broken out into two separate leaves, Vacation Leave and Health Leave. The new term Health Leave is to encompass all types of leaves that may be affecting your health, your mental health,  or the health of someone who is an immediate family member or a dependent child.



Learner Disability Assessment and PsychoEd Evaluation Policy

Policy Statement

It is recognized that trainees in our GME programs may benefit from having a learning disability assessment and/or a psycho-educational evaluation. This may include an assessment for attention deficit hyperactivity disorder (ADHD).

The costs associated with learner disability assessments and psycho-educational evaluations are the responsibility of the trainee. Some forms of assessment may be covered by health insurance.

When not covered by health insurance:

    • The program may choose to share in the cost of the assessments if they determine it is in the best interest of the trainee and the program to do so.
    • If the assessment or evaluation is a condition of the trainee’s appointment, then the cost of the assessment or evaluation is the responsibility of the program.


Trainees seeking these types of assessments should work with the Medical School’s Director of Learner Development for referral to appropriate assessment resources.

Licensure Policy

Policy Statement

The Minnesota Board of Medical Practice (MBMP) is the state entity that regulates physicians practicing in Minnesota. All trainees must hold an active residency permit or a physician license from the MBMP as determined by each individual residency/fellowship program. The statute can be found at: Trainees must pass the required licensing examinations (i.e. USMLE, COMLEX, etc) prior to obtaining a medical license.


The Permit/License Guide is kept up-to-date. Review the guide to ensure your understanding of the process.

Residency permits are valid through the term specified on the original permit application and are program specific. If a trainee extends their residency/fellowship, the program is responsible for ensuring that a permit extension request form is submitted to the MBMP prior to the current permit end date. An extended permit must be in place prior to the original permit end date and must cover all dates of clinical training. If a trainee transfers to another program a new permit must be obtained.

Trainees who moonlight outside their training program must have a physician license. Minnesota licenses are renewed annually based on birth month. Once a Minnesota license is obtained, the permit is no longer valid and the trainee and program must ensure the license is renewed annually.

Programs are responsible for monitoring renewal deadlines and ensuring that trainee’s permits or licenses do not expire. Please note there is no “grace” period when a permit or license expires. Trainees whose permit or license expires are pulled from their rotation until the paperwork is received and processed by the MBMP.

Related Information

Trainees holding a Minnesota medical license do not need to be credentialed by the hospitals they are rotating to as long as they are performing duties within the scope of their training program and not billing for their services. A physician holding a Minnesota license has to be credentialed by the hospital if they are acting as an independent physician where there will be patient billing (i.e. moonlighting). Please refer to the MBMP website for licensure guidelines and fees.

Additional information related to visiting residents and fellows is available on the GME website.

Minnesota Board of Medical Practice
University Park Plaza
2829 University Ave, S.E., Suite 500
Minneapolis, MN 55414-3246
Telephone: (612) 617-2130, Fax: (612) 617-2166


April 24, 2018: Specific Minnesota Board of Medical Practice process details removed from policy.

  • Origination Date: July 2011
  • Last Review Date: April 24, 2018
  • Next Review Date: April 2020

Life Support Certification Policy

Policy Statement

Upon entering an accredited GME training program all trainees who have direct contact with patients must be certified in BLS and/or ACLS, PALS, etc. depending on the program requirements.  Certification is typically valid for two years. Once the initial certification expires, only those trainees required by the hospital to have BLS and ACLS and/or PALS or any other lifesaving certification will be recertified at the teaching hospitals expense.


Program Responsibilities: If life support course recertification is required by the program, the program will be responsible for the expense.  If re-certification is requested by the trainee, but is not a program requirement, the trainee is responsible for any fees.

Documentation and record-keeping of initial certification and recertification is the responsibility of each program. 

Related Information

Additional information is available below in the "Life Support Certification Procedure".

Life Support Certification Procedure

Required: Report life support certification in RMS

Programs are required to upload life support certification information and documentation about each of their trainees to RMS. Programs must upload this information regardless of where the resident/fellow received certification.

Life support certification at Fairview

Fairview Contact:

Terry Nelson
Fairview HR BLS/ACLS Coordinator

Basic Life Support (BLS)

New to UMN residents/fellows who attend a MHealth Fairview American Heart Association BLS course are issued a BLS Provider card.  The BLS training is valid for two years.  

BLS Renewal: BLS recertification is required every two years by M Health Fairview. There are two options for re-certification:

  • Complete the M Health Fairview BLS review course. Those who complete the M Health Fairview review are issued a statement of attendance (minimum requirement at M Health Fairview).
  • Complete the M Health Fairview BLS review course plus the online AHA didactic training, which carries a fee of $22, plus an additional $5 to receive an AHA BLS card (vs. a statement of attendance). This is currently a charge that must be incurred by resident/fellow.

Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), & Neonatal Resuscitation (NRP)

UMN residents/fellows required by their programs or M Health Fairview to maintain these advanced skills can complete a certification class. They are issued an AHA or AAP card. This training is valid for two years from the date of issue.


  • UMN residents/fellows required by their programs or M Health Fairview to maintain these skills can schedule a renewal depending on class availability. AHA or AAP cards are issued for all ACLS/PALS/NRP renewal classes and valid for two years from the date of issue.
  • If advanced life support courses are not required residents/fellows may register if room is available. There would be a fee upon registration.

Life Support Certification at VAMC

VAMC Contact:

Wendy Dahl
Director, Advanced Life Support Training

The VA is offering ACLS and/or BLS training for the residents during the COVID pandemic.  Residents/fellows that are rotating at the VA through December 31, 2020 (this date may be extended but it's unknown at this time if it will and for how long it will be extended through) can obtain their ACLS and/or BLS certification online followed by the VAM (Voice activated manikin) station for skills testing. Availability of this option in 2021 is unknown at this time.

Process is as follows:

  1. A VA liaison staff member (site coordinator) verifies which course (ACLS or BLS or both) is required for the VA rotation and verifies that the resident/fellow is rotating at the VA prior to the expiration of this offer.
  2. Once that information is verified, the liaison person sends Wendy Dahl a name with certifications needed and expiration dates of certification status currently.  Wendy will assign the course/s in TMS where residents/fellows can complete the course/s. Staff should not try to self-enroll, as this process does not work. The VA does not provide key codes to anyone anymore.
  3. Each resident/fellow must have an active PIV Card to access the VA CPR (VAM skills test stations in our library 4U-100) in order to complete the course.
  4. Certification completion cards are located within the completion course itself for the residents/fellows to print as the VA no longer prints cards.

Acceptable proof of certification at VAMC
If your UMN resident/fellow is rotating to the VAMC and has already completed Life Support Certification, VAMC accepts proof of certification via completion certificate, BLS card, etc. (In the past, only AHA cards were accepted at VAMC.)  VAMC considers the American Heart Association training the gold standard and recommends it; however, VAMC will accept the M Health Fairview hands-on training.

Life support certification at other affiliated hospital sites
Review the UMN GME Affiliated Sites Life Support Certification Resource for information, costs, and contacts for scheduling life support certification training at other affiliated hospital sites.

American Heart Association life support certification courses
Go to the AHA’s courses site to view life support certification course options, locate training centers, and review course content.

Moonlighting Policy

Policy Statement

Trainees must not be required to engage in moonlighting activities.

PGY-1 residents are not permitted to moonlight.

Programs are not required to permit moonlighting for their trainees and may choose to disallow these activities as a matter of program policy.

Moonlighting must not interfere with the trainee's ability to achieve the goals and objectives of the training program.

Moonlighting activities are not considered to be part of the educational curriculum in University of Minnesota residency and fellowship programs.

Time spent moonlighting must be reported as a part of duty hours monitoring and must be included in assessments of compliance with ACGME duty-hour requirements.

Trainees on J-1 visas are not permitted to be employed outside their training program and are not permitted to moonlight.

Trainees on H-1B visas must obtain separate H-1B visas for each facility where the trainee works outside the training program.

Trainees must seek and receive written permission from their program director BEFORE engaging in moonlighting activities, and the program must retain a copy of this correspondence in the trainee's personnel record in RMS. This permission must acknowledge the trainees understanding that

  • their trainee professional liability coverage through the University of Minnesota does not cover moonlighting activities,
  • moonlighting activities must not interfere with their achieving program goals and objectives, including compliance with duty hour regulations, and
  • the program director may review moonlighting activities at a later date and reserves the authority to withdraw permission to moonlight.

Reason for Policy

The purpose of this policy is to provide residents/fellows (trainees) and their programs with information on managing moonlighting in compliance with ACGME requirements, CMS regulations, immigration law and the Minnesota Board of Medical Practice. If statements in this policy contradict those of ACGME, CMS, immigration law or the Minnesota Board of Medical Practice, those policies take precedence.


  1. The trainee thoroughly reviews the institutional moonlighting policy, their program moonlighting policy and the moonlighting request form.
  2. If the trainee’s program allows moonlighting, the trainee must complete the University of Minnesota Graduate Medical Education Standard Moonlighting Request Form (see below in forms)
  3. The trainee must complete all sections of the form and present it to their program director for review.
  4. The program director may deny or approve the request.
  5. If the program director approves the request the trainee may proceed with applying to moonlighting at the approved site.
  6.  If the program director denies the request, the trainee may not moonlight.
  7. The fully executed moonlighting request form (all signatures obtained) will be uploaded to RMS by the program.  It will reside in the files and notes section of the trainee’s personnel record in RMS.
  8. The program must use this naming standard as they scan and save the completed form: Moonlighting Request Form Year/Month_Last Name, First Name (e.g. Moonlighting Request form 2013.10_Smith, John)


University of Minnesota Graduate Medical Education Standard Moonlighting Request Form



  1. Trainees who wish to moonlight must obtain prior permission from their program directors, using the approved University of Minnesota Graduate Medical Education Standard Moonlighting Request Form. Failure to get prior approval is grounds for discipline under Section VI of the Residency/Fellowship Agreement.
  2. Trainees must report moonlighting as a part of their duty hours in the Residency Management Suite (RMS).


  1. The Program Director determines the moonlighting policy for all trainees within their program.
  2. Program directors will acknowledge in writing (via approval of the moonlighting form) their awareness that a trainee is moonlighting and will include this information in their training file.
  3. Program directors may withdraw permission to moonlight for any given trainee or group of trainees at their discretion.

Multidisciplinary Program Policy

Policy Statement

Multidisciplinary training programs involve several distinct specialities in order to meet curricular requirements. An ACGME-accredited multidisciplinary program must be aligned with, and function as, an integral part of multiple residency program(s) at the sponsoring institution, as reflected in the respective program requirements. For multidisciplinary programs, only one ACGME-accredited program can exist within a sponsoring institution.

There must be collaboration among the multiple disciplines and professions involved in educating the fellows in a multidisciplinary program. The educational resources required to support the program necessitate cooperation of all the involved disciplines. A single multidisciplinary oversight committee must regularly review the program's resources and its attainment of its stated goals and objectives.  


The program director of a multidisciplinary training program must maintain a membership roster for the multidisciplinary oversight committee and minutes of its meetings.


Multidisciplinary programs are co-sponsored by multiple specialties and accredited by multiple Residency Review Committees (RRCs). They require the collaboration of several distinct specialties to meet curricular requirements.

This policy applies to all ACGME-accredited multidisciplinary programs at the University of Minnesota.  As of the time of last policy review, this includes:

  • Clinical Informatics (in development)
  • Endovascular Surgical Neuroradiology
  • Molecular Genetic Pathology
  • Pain Medicine


2/23/2016: Approved by Graduate Medical Education Committee.

9/26/2017: Policy reviewed by GMEC. List of UMN multidisciplinary programs updated.


NIH NRSA Training Grant Appointment

Policy Statement

Residents/fellows (trainees) who are moved to one of these four NIH NRSA appointments:

  • 9582 NIH NRSA Medical Resident
  • 9583 NIH NRSA Medical Resident – Graduate Program
  • 9568 NIH NRSA Medical Fellow
  • 9569 NIH NRSA Medical Fellow – Graduate Program

must be given thirty (30) days notification of change in appointment from their program.  See program responsibility.

Trainees on NIH NRSA Training Grants:

  • Are exempt from FICA withholdings and must have non-service appointments in one of the four approved classifications.
  • Have health, dental, life, long and short-term disability and malpractice insurance.
  • Receive benefits from the UCard such as access to the libraries, discount tickets, ADCS computer labs, etc.
  • Have access to the Recreational Center but will have to pay membership fees.
  • Have access to the Residency Assistance Program (RAP).

Trainees on NIH NRSA Training Grants:

  • Are not eligible for Health Care Reimbursement account or Dependent Care Reimbursement account.
  • Are not eligible to participate (withhold funds from your pay) in the Optional Retirement Plan (ORP) or the University of Minnesota Section 457 Deferred Compensation Program (457 Plan).
  • Are not eligible to deduct parking fees on a pre-tax basis 

Reason for Policy

Per NIH policy, training grants are to be used for trainees pursuing academic research careers and are not provided as a condition of employment, which means that benefits associated with employees cannot be provided to trainees on National Research Service Award (NRSA) training grants from the National Institutes of Health (NIH).


Trainees on NIH NRSA Training Grant and Enrolled in Graduate School will:

Continue to be registered for courses and tuition and fees will be paid. The payment of tuition and fees for your graduate courses, along with keeping your registration current, will continue your status as a fee paying student and allow you access to the U of M Recreation Center.  



Provide trainee with a letter of notification of change in appointment no later than 30 days prior to the change in appointment.

Per our stipend level appointment policy, “Trainees in all programs at the same level of training must be paid in accordance with the stipends set by the Graduate Medical Education Committee (GMEC).  Trainees may not be paid less than or in excess of the stipend set by the GMEC for their level of training.” Programs must supplement the funds received by the NIH NRSA training grant in order to pay the trainee at the approved stipend for their level of training.


In 2005, the University’s general counsel and external legal counsel reviewed NIH and IRS regulations in partnership with a workgroup. The workgroup consisted of staff from various departments within the University (Tax, Payroll, HR, Sponsored Projects Administration, General Counsel, Graduate School and Medical School).  The policy and procedure is the work product of the work group.

Nursing Mother Policy

Policy Statement

In accordance with State and Federal laws, residency and fellowship training programs must provide adequate break time for nursing mothers to express milk for up to one year after the birth of their child.  Trainees and program directors/chief residents must develop a schedule that works for the trainee but does not cause undue hardship to the training program. 

The University of Minnesota provides Nursing Mother's’ rooms which are located across campus that are quiet, comfortable rooms where a nursing mother can express and store their breast milk. Under The Patient Protection and Affordable Care Act, nursing mothers cannot be required to use a public/private bathroom to express milk.


Mothers wishing to continue nursing after returning to work should develop a plan with their program director or chief resident to insert reasonable breaks during the day to express milk. 

Nursing mothers rotating to other hospitals/sites should contact the GME coordinator or site director to identify a private room where you can express as well as arrange breaks during your rotation.

Please refer to this webpage for more information:

Related Information

The University of Minnesota Graduate Medical Education administration and training programs supports your decision to continue to provide breastmilk for your baby.  Breastfeeding has been shown to significantly improve the health and wellbeing of your baby and you.





Orientation Policy

Policy Statement

All incoming residents and fellows, starting in both ACGME-accredited and non-accredited programs, are required to attend a GME orientation session.  This requirement includes those trainees moving from one University of Minnesota program to another.

Reason for Policy

Central orientation provides valuable information about GME at the University of Minnesota, promotes interaction with important resources, welcomes trainees to the sponsoring institution, and provides them an opportunity to network across programs.


Updated orientation requirements and procedures are communicated via email and on the Incoming Residents & Fellows Orientation page on the GME website.


Programs are expected to support and encourage their trainees’ attendance at institutional GME orientation, and to facilitate attendance through their management of the trainees’ schedules.

The GME office will communicate with program coordinators to finalize which orientation date each trainee will attend, and will communicate directly with trainees regarding orientation and onboarding requirements.


Professional Dress Code Policy

Policy Statement

Every resident/fellow is a representative of the University of Minnesota and of the hospital at which they are completing their GME training. Resident/Fellows are expected to project a professional and positive image to patients, visitors, and fellow employees. Residents/Fellows should present a good appearance, including good personal grooming and hygiene, appropriate dress for the work being performed, and by wearing proper hospital identification while training. Trainees are expected to dress according to generally accepted professional standards appropriate for their training program.  Each individual’s training program may set more specific guidelines for dress code. Each individual’s training program may evaluate and make determinations regarding dress code policy compliance.

Reason for Policy

To establish guidelines to ensure that the resident/fellows portray a professional image to the patients, visitors, and fellow employees that allows for the safe performance of job duties when working at a trainee hospital location. 


General Dress Guidelines

The resident/fellow’s personal appearance while on duty, or in areas where contact with patients or their families is possible, shall be neat, clean, professional.

Professional Dress

Professional Dress

Blouses, sweaters, suit or sport jackets,professional shirts, dress shirts, sweaters, polo-type shirts, turtlenecks, dress pants, slacks,trousers, khaki type slacks, skirts, dresses, skirted suits, professional dresses and skirts with or without slits should be knee length or longer.

Tight fitting or revealing garments, blue jeans, or items of clothing imprinted with advertising or objectionable language are prohibited.  


Closed-toed shoes that completely cover and protect the tops and sides of feet should be worn.

Lab Coat/ Scrub Suits

Lab coats and scrub suits should be worn as directed by the applicable program, and should be clean and without signs of wear or stains.

ID Badge

The trainee’s identification badges are to be worn at all times at the trainee hospital. ID Badges need to be visible and worn above the waist.


Grooming Guidelines


Fragrance is strongly discouraged due to patient sensitivities and allergies.

Facial Hair

Mustaches and beards should be clean, neatly groomed, and moderate. 


Fingernails are to be kept clean and neatly trimmed and of an appropriate length to perform job duties.  Artificial nails are prohibited from being worn by any direct patient care staff. 


Hair shall be neat, clean, of a natural occurring or naturally occurring dyed color. Extreme haircuts are inappropriate.


Jewelry or body piercing should not interfere with direct patient care or other on duty responsibilities.




February 28, 2017 -The Professional Dress Code Policy was reviewed by the Resident Leadership Council in comparison to Dress Code Policies of similar GME hospital sites, locally and regionally. The comparison provided a need for more specific descriptions to the current policy. The policy statement language was updated completely to encompass an overview of the policy and recognizes that each program specifically may have separate guidelines. General dress guidelines were established. An in-detail description of appropriate and inappropriate ‘Professional Dress’ and ‘Grooming Guidelines’ were established. The GMEC approved the updated Professional Dress Code Policy on February 28th, 2017 at the GMEC monthly meeting.


Residency/Fellowship Agreement Policy

Policy Statement

The residency/fellowship (trainee) agreement is a required, binding contract between the trainee and the institution.  The effective date of the initial agreement is the first mandatory date the trainee is required to report to their GME training program.

If the resident/fellow is in satisfactory standing, the agreement will be automatically renewed on an annual basis for the duration of the training program.

There are no restrictive covenants on the post-training employment opportunities of trainees.  Residents/fellows are free to compete for any physician or academic positions in any geographic area following completion of their training.


The agreement template is reviewed no less than annually by GME Administration in collaboration with the Office of the General Counsel.  GME Administration presents recommended revisions to the Graduate Medical Education Committee (GMEC) for their review, discussion and approval. 

GME Administration ensures that each trainee’s agreement is fully executed (all parties have signed and dated the document) prior to the effective date, and saved to the trainee’s RMS Personnel record.  The scanned copy is the official agreement.


Resignation or Transfer Policy

Policy Statement

Residents/fellows who wish to resign before completing their training program must give at least a 30 day notice unless an exception is made by the Program Director, who must notify the Associate Dean for GME in writing.  Notice must be given in writing to the Program Director.  All conditions of appointment will terminate on the effective date of the resignation.


Procedure for Resignation

  1. The resident/fellow must submit a letter of resignation (template at this link) to the Program Director at least 30 days prior to the projected date of resignation.
  2. The Program Director must acknowledge receipt of the resignation in writing.
  3. The Program Director must notify GME Administration/Associate Dean for GME in writing. 
  4. The Program Director must provide information reviewing the circumstances of the resignation and any counseling/services/remediation rendered.
  5. Department/program must follow the steps outlined in the graduating/transitioning checklist.

Procedure for Transfer

  1. Resident/fellow must submit a letter of intent to transfer to the Program Director at least 30 days prior to projected transfer date.
  2. The Program Director must acknowledge receipt of the intent to transfer in writing.
  3. The Program Director must communicate in writing with the Program Director where the resident/fellow is transferring. 
  4. Department/program notifies GME Administration/Associate Dean for GME of the intent to transfer to another program.
  5. The Program Director must provide information reviewing the circumstances of the transfer and any counseling/services/remediation rendered.
  6. Department/program follows the steps outlined in the graduating/transitioning checklist.

Related Information

Verification of Training and Summary for Credentialing Policy and Procedure

Social Media Policy for AHC Students, Residents and Fellows

This policy provides guidance and parameters for social media (see Definitions) usage by students, residents and fellows enrolled in Academic Health Center (AHC) educational programs. While social media tools are a very popular mode of engagement and communication and facilitate education, collaboration, research, business, and remote work, its usage by AHC students, residents and fellows presents unique risks to clients/patients. Because of the risks associated with inappropriate use of social media, misuse must be addressed through professionalism training, usage guidelines, and appropriate corrective and disciplinary action when warranted. The use of social media requires a conscious recognition of the profoundly public and long-lasting nature of communication via social media which provides a permanent record of postings. Each student, resident and fellow is responsible for appropriate behavior using social media just as they are with communications in other areas of their professional life.

Stipend Level Policy

Policy Statement

Trainees in all programs must be paid in accordance with the stipends set by the Graduate Medical Education Committee (GMEC).  For every program, each program level is associated with a standard stipend step.  Trainees may not be paid less than or in excess of the stipend step set for their program level of training, except as noted below.


  • H-1B visa holders must be paid the higher of the prevailing wage determined by the U.S. Department of Labor, or their program level stipend step.
  • Trainees holding a Without Salary appointment, per the Without Salary Appointment Policy.

Reason for Policy

To provide consistency regarding stipend levels within individual programs and across the institution, and clarity for residents/fellows, faculty, and program and department staff.

Related Information

It is recognized that there are trainees accepted into training programs who have completed additional GME training above and beyond what is required for the training program they are entering (e.g. additional fellowships, an additional year chief residency, etc.).  Trainees may have also spent time in non-GME activity (e.g. employment, graduate school, etc.).  While these accomplishments are noteworthy they do not impact the stipend level.

See also:



July 25, 2017: Instituted standard stipend steps for each program level of training.  All trainees at the same level in a program will receive the same standard stipend step.  (For instance, all trainees in XYZ Fellowship training at Program Level 1 will receive Stipend Step 5, regardless of their individual prior training history.)  The association between program level and stipend step will be set on a program-by-program basis.

April 25, 2017: Removed exception for trainees on NIH NRSA grants to be paid at the rate set by the grant.

Prior revision dates: June 27, 2003; October 4, 2005; April 13, 2006; April 11, 2007; March 31, 2008


January 24, 2003: Approved by the Graduate Medical Education Committee (GMEC).


Supervision Policy

Policy Statement 

There must be sufficient institutional oversight to assure that trainees are appropriately supervised.  Appropriate supervision means that a trainee is supervised by the teaching faculty in such a way that the trainees assume progressively increasing responsibility according to their level of education, proven ability, and experience.  On-call schedules for teaching faculty must be structured to ensure that supervision is readily available to trainees on duty.  The level of responsibility accorded to each trainee must be determined by the program director and the teaching faculty.

Reason For Policy 

To ensure that the UMMS GME programs provide appropriate supervision for all trainees that is consistent with proper patient care, the educational needs of trainees, and the applicable ACGME Review Committee (RC) and Common Program Requirements.

Program Responsibilities 

It is the responsibility of individual program directors to establish detailed written policies describing trainee supervision at each level for their residency/fellowship programs.  The policies must be maintained in the Program Manual. 

The requirements for on-site supervision will be established by the program director for each residency/fellowship in accordance with ACGME guidelines and should be monitored through periodic departmental reviews, with institutional oversight through the GMEC internal review process.

Programs should establish policies that support Effective Supervisor Behaviors, see related information.

Set clear expectations

  • When to call
  • Situations in which trainees should always call
  • How to call – provide accurate pager/phone numbers
  • Trainee’s role in the care of the patient

Create a safe learning environment

  • Reassure the trainee that is is always appropriate to call if uncertain
  • Recognize and address uncertainty in the trainee

Be readily available

  • Answer pages and phone calls promptly
  • Planned communication (schedule times for calls)

Balance supervision with trainee autonomy.  Provide input but don’t take over the case

Be respectful

  • Be patient with the trainee regardless of time of day
  • Don’t yell at or belittle a trainee

Transportation and Safety Policy

Policy Statement

Residents and fellows (trainees) rotating at the affiliated sites listed below, who are too impaired (or are identified by their peers as being impaired) to drive home safely, can request a transportation voucher.  

Trainees identifying risk and safety while arriving and/or departing work should seek security services at the site they are training at to address those needs.  Security services for each site are listed below in the procedures.


Each site has individual instructions on how to obtain a transportation voucher and the amount granted per request listed below.  The transportation fare may be used to the trainee’s home or a closer location if the trainee so chooses.

  • University of Minnesota Security (East & West Bank)

University Security acts as the security presence on campus, with the distinctive “hi-vis” green and gray uniform seen around campus, in libraries, residence halls, on bike patrol and providing the 4-WALK safe walk service. Security Monitors are given training in First Aid, CPR, and use of an AED. Security Monitors are equipped with a First Aid Kit and a portable police radio in the event of an emergency.

The safe walk service provides free walking and biking security escorts to and from campus locations and nearby adjacent neighborhoods for all students, staff, faculty and visitors.

      • To request a safe walk from a trained student security monitor, please call 612-624-WALK (9255), or 4-WALK from any campus phone, shortly before your desired departure time. Your safety is our first priority!
  • University of Minnesota Security (Duluth)

Safewalk Escorts: Kirby Student Center, 1120 Kirby Dr, Duluth, MN 55812

      • Call 218-726-6100
  • University of Minnesota Medical Center (UMMC)

Transportation/Cab vouchers will be provided by University of Minnesota Medical Center and distributed in the following way:

      • Monday-Friday daytime hours: contact Social Work Services at University Campus: 612-273-3366. Riverside Campus: 612-273-6797.
      • Evenings and weekends: contact the Administrative Supervisor @ University Campus pager: 612-899-9000.  Riverside Campus pager: 612-613-8497.

If there are any problems or issues that arise as a result of this policy, please contact UMMC GME at 612-273-7482.

  • University of Minnesota Medical Center (UMMC) Security
      • Call for a safety escort at: 612-273-4544
  • Children’s Hospitals and Clinics of Minnesota

Transportation/ Cab vouchers will be provided by Children’s hospital for an amount up to $35.00 per post call date and any additional cab fare will be borne by the resident or medical student  and distributed in the following way: 

Monday- Friday: 

      • Minneapolis Contacts are the Chief at 612-813-6070 or the Coordinator at 612-813-6206. 
      • Saint Paul Contacts are the Chief at 651-220-6132 or the Coordinator at 651-220-6131.


      • U of M Operator (to page the Chief on call): 612-273-3000
      • Corinne Wilcox-Schowalter Cell: 612-655-6480

Preferred Cab Companies: 

      • Minneapolis: Red and White Cab: 612-871-1600
      • Saint Paul: Yellow Cab: 651-222-4433, Red and White Cab: 612-871-1600
  • Children’s Minnesota’s security department: 

Provides security escorts upon request to anyone at the Minneapolis and St. Paul hospital campuses 24 hours a day. Depending on availability of officers there may be a delay between time of request and escort.  Security escorts will be provided on foot or by use of the security vehicle between parking lots/ramps and the hospital/buildings associated with the hospital. Security escorts will not be provided within the hospital or within its connecting buildings unless the security shift supervisor approves the escort. Security escorts for on-street parking will be restricted to within one block of the hospital campuses.

All residents and fellows at HCMC who feel they are too impaired, or identified by peers as being too impaired, to drive home safely after working a call shift will have the opportunity to return home and return to work using a cab voucher.

    1. Obtaining a Ride
      • Residents/fellows may call Yellow Cab directly at 612-888-8889 and indicate that this is a non-patient transport request for Account HCMC GME, account # 1556, and give your name.

         2. Reimbursement

      • The maximum voucher will be $35.00 per call date.
      • Any additional cab fare will be borne by the resident/fellow.
      • The maximum reimbursement will be to the resident/fellow’s home.
  • Hennepin County Medical Center (HCMC) Security: 

Are availablefor staff, patients, and visitors to use to and from your cars. Either use the buddy system when your shift is over or request a Security escort to and from your car. 

      • Stop by the Security booth or call 612-873-3232 to arrange an escort
  • Minneapolis VA Health Care System (MVAHCS)

Reimbursement will be provided to Residents and Fellows who are too fatigued to safely drive home after working a call shift.

      • Reimbursement will be to the Resident/Fellow home only.
      • All receipts will need to be turned in for reimbursement.
      • Contact: Site supervisor or site coordinator

Security escort can be available for staff upon request.

      • If a resident/fellow feels at risk, they can call non-emergent VA Police for escort prior to departure.
      • Contact: From a VA internal phone, dial x312007
  • Regions Hospital 

Regions Hospital will provide a cab voucher to trainees who are too fatigued to safely drive home. 

      • Contact: The site supervisor or site coordinator



June 27, 2017 - The Cab Voucher Policy was reviewed by the AY 17-18 Resident Leadership Council (RLC). With evolving modes of transportation and constant changes within the affiliated sites, this policy had not been revised since 2012. The RLC has changed the policy name from ‘Cab Voucher’ to be more inclusive. The new ‘Transportation and Safety Policy’ will now include updated information on the affiliated sites and University of Minnesota campus transportation and safety procedures.

Effective: July 25, 2017 - Transportation and Safety Policy was approved by the Graduate Medical Education Committee (GMEC).

University of Minnesota Policy on Racial or Ethnic Harassment

Policy Statement

The University of Minnesota Medical School follows the policy of the University of Minnesota:

University of Minnesota Policy on Sexual Harassment, Sexual Assault, Stalking and Relationship Violence

Policy Statement

The University of Minnesota Medical School follows the policy of the University of Minnesota: 


The University of Minnesota Medical School follows the procedure of the University of Minnesota:

Vaccination and Immunization Policy for Learners in the Health Sciences

The GME office abides by the Academic Health Center Policy for immunizations.

Visa Sponsorship Policy

Policy Statement

To outline the acceptable and not acceptable visa types at the University of Minnesota for Graduate Medical Education training programs. 

Visa Types

Acceptable visa types for a residency/fellowship are:

  1. J-1 visa—Alien Physician: the preferred visa for residents/fellows who are not United States citizens or permanent residents, issued by the Education Commission on Foreign Medical Graduates (ECFMG);
  2. J-2 visa: issued to the dependent of a J-1 visa holder (read J-2 Visa Procedure below);
  3. H-1B visa: requires GME approval (read H-1B Visa Procedure below);
  4. Permanent Residence Application pending: candidates in this situation will be issued an Employment Authorization Document (EAD) card which must be renewed annually.  Contact Visa Manager for further information.

Not Acceptable visa types for a residency/fellowship are:

  1. F-1 student visa: issued only to students who are attending college/university (including medical school), high school, private elementary, seminary, conservatory, or another academic institution, including a language training program in the United States.
    • An F-1 Student can train in a Graduate Medical Education program on a F-1 Post Graduation Optional Practical Training (OPT): an extension to F-1 visa for the first year of residency training.  Requires additional permissions from International Students & Scholar Services (ISSS).  Contact Visa Manager immediately if the candidate is interested in OPT for requirements and procedures.
  2. M-1 Student Visa: issued for vocational or other recognized nonacademic institution, other than a language training programs;
  3. O-1 visa: nonimmigrant visa is for  individuals who possess extraordinary ability in the sciences, arts, education, business, or athletics, or who has a demonstrated record of extraordinary achievement in the motion picture or television industry and has been recognized nationally or internationally for those achievements. 


J-1 Visa—Alien Physician Procedure

The J-1 alien physician visa is sponsored by the Education Commission for Foreign Medical Graduates (ECFMG), and is the preferred visa of University of Minnesota Medical School residencies and fellowships. Please contact your Program Coordinator to verify if J-1 visa sponsorship is allowed in your program.

All ECFMG J-1 applications originate online via EVNet, and are initiated by the ECFMG Training Program Liaison (TPL) for the University of Minnesota.  Information on the required documents for the J-1 application can be found on the ECFMG website:

ECFMG requires notification on trainees who are on a J-1 visa for elective rotations, remediations, leave of absences, dismissal, resignation, and any incidents/allegations. To learn more about the required notifications please see the Required J-1 Visa Holder Notification Policy.  

J-2 Visa Procedure

Any residents/fellows training on a J-2 visa are required to obtain an EAD card on an annual basis.  Renewal can take up to six (6) months processing time.  The J-2 spouse is responsible for ensuring that the J-1 spouse applies for J-1 visa renewal annually and allows enough time for EAD card renewal for the J-2 spouse.  The J-2 spouse must also inform the program of any changes to the J-1 spouse’s visa sponsorship, as J-2 sponsorship is directly linked to J-1 sponsorship.  The program must obtain a signed J-2 offer letter from the Program Director and signed by the J-2 spouse annually; contact the Visa Manager for the template. 

H-1B Visa Procedure

At the discretion of the individual training programs, the H-1B visa may be considered for candidates who have passed the USMLE Step 3 exam and who provide documentation that meets one or more of the following criteria:

  1. Applicant currently holds a valid H-1B visa at this university or another institution (provide copy of Form I-797, Notice of Action)
  2. Applicant is the spouse/registered domestic partner of a U.S. citizen, permanent resident (“green card” holder), or individual holding an  H-1 or O-1 visa (provide copy of marriage certificate or H-4 document)
  3. Applicant/applicant’s spouse has a permanent resident petition pending with a likely chance of success (provide copy of proof of petition)
  4. Applicant is not eligible for or would face a hardship on a J-1 visa due to unique immigration circumstances (e.g., applicant already obtained a J-1 waiver; applicant who has to return home periodically  to care for ill parent faces higher risk of being denied re-entry on J-1 visa ) (provide letter explaining reason for hardship)
  5. Applicant’s spouse/registered domestic partner is employed by the University in a faculty or other continuing position (provide letter identifying spouse’s position)
  6. Applicant is a graduate of a medical school in the United States, Canada or Puerto Rico accredited by the Liaison Committee on Medical Education (LCME) (provide copy of medical school diploma)
  7. The department has offered or is strongly considering the applicant for a faculty or research position after applicant completes the training program (provide letter identifying intentions of department after applicant finishes training program)

In addition to meeting allUMN eligibility and selection criteria, H-1B visa applicants must meet additional eligibility requirements: they must have passed USMLE Step 3 and also hold a MN residency permit (at minimum, or MN medical license if applicable) prior to submitting their H-1B visa application. 

Prior to scheduling an interview, the program must provide all applicants with a copy of the institutional visa policy and the program-specific policy on offering H-1B visas.

To obtain GME approval for all H-1B visas, the program must submit a completed H-1B Visa Request Form and the documentation that supports one or more of the criteria for offering an H-1B visa to an incoming resident or fellow.  The GME office will respond in writing to the department/program indicating whether the request to apply for the H-1B visa is approved or denied. 

Training programs are responsible for ALLcosts and fees associated with preparing and filing H-1 B visas for residents/fellows.  This includes supplementing stipends to meet the prevailing wage requirements, if applicable.  Training programs are required to use the services of International Student and Scholar Services (ISSS) or work through the Office of the General Counsel at the University to obtain outside legal counsel for this purpose.

If a training program terminates or non-renews a resident/fellow appointment before the individual’s H-1B visa expires, the training program is responsible under U.S. Citizenship and Immigration Services regulations to pay the H-1B physician’s airfare back to his/her home country.



Ensure that visa sponsorship forms are completed annually or before the current visa’s expiration date, whichever comes first.



  • Moonlighting for residents/fellows on J-1 visas is not permitted under any circumstances.
  • A resident/fellow on an H-1B visa wishing to moonlight must obtain a separate H-1B visa for each facility where the resident/fellow works outside the training program. 

Related Information


8.2020: The Visa Sponsorship Policy was updated in August 2020 to address the O-1 visa. The updated policy states that the O-1 is not an eligible visa type for Graduate Medical Education.  

Previously the GME office was approving O-1 visas to those candidates that met our Eligibility and Selection Policy (Extraordinarily Qualified Candidate) pending the immigration attorney's determination  of extraordinary ability. Because trainees are learners they do not fit the definition of extraordinary ability required for this visa.To more clearly define what is acceptable and not acceptable Graduate Medical Education visa types, the section above was split into two sections.


Workers' Compensation Procedure

Policy Statement

University of Minnesota Policy: Reporting Workers Compensation Related Injuries


View detailed information about management of needle sticks, blood borne pathogen exposure (BBPE), and tuberculosis exposure here: Occupational exposures and worker’s compensation claims

Review this policy for information on all other medical resident or fellow worker’s compensation injuries.

The University is committed to providing medical residents and fellows with comprehensive medical care for on-the-job injuries. When a resident or fellow is injured during training, they must take immediate steps to report the injury to the University.

Complete an Online Electronic First Report of Injury (eFROI)

You are REQUIRED by the Department of Labor and Industry to submit an e-FROI within 8 business hours (1 workday).  It is also necessary for a worker’s compensation (WC) claim to be filed so that the bills incurred as a result of the injury are paid. 

  1. Access the online eFROI via the UMN Risk Management Office.  You are required to complete the ONLINE version. 


  1. Campus Selection: Choose "Twin Cities All Other" in the drop-down for the campus in the e-FROI.

  1. Supervisor: List the superviser on duty when the incident occurred (ex. Attendee, Program Director, Chief Resident, etc).

  1. You will hear from an adjuster at Sedgwick Claims Management (SCM) within 3 business days of submission of the completed eFROI. If you do not hear from SCM within 3 business days, contact the Office of Risk Management at 612-624-5884 or e-mail to to make sure that your e-FROI was received at Sedgwick. 

  1. If you receive a bill as a result of the injury, please retain the bill and fax it to Sedgwick Claims Management at 952-826-3785.


420 Delaware Street SE, MMC 293
Minneapolis, MN 55455

Phone: 612-624-5621