Visiting Medical Student Senior Elective Application

UNIVERSITY OF CHICAGO

VISITING MEDICAL STUDENT SENIOR ELECTIVE APPLICATION

924 E. 57th Street, BSLC - 104 Chicago, IL 60637-5416

(773) 834-3757 (Phone) (773) 834-1920 (Fax)

Note to applicants: A complete application does NOT guarantee acceptance or admission. Please do not make travel arrangements until you have received eligibility confirmation from the Center for Global Health's program coordinator and the Pritzker School of Medicine.

SECTION 1 - TO BE COMPLETED BY STUDENT

Date of Application

Student Name (LAST Name, FIRST Name) Citizenship Date of Birth

Current Address with City/State/Zip Code

Current/Best Email Address Best Phone (No dashes)

Country of Citizenship Passport number

Country of Legal Residence

City and Country of Birth

Type of US Visa (if already obtained)

MUST BE COMPLETED:

I am a year matriculated medical student in a -year program at the. Only students who have completed a comprehensive third year educational program may apply for fourth year electives at the University of Chicago, which includes 3 months of Internal Medicine, 3 months of Surgery, 2 months of Pediatrics, 1 month of Obstetrics and Gynecology, 1 month of Psychiatry, and 1 month of Family Medicine, but is not limited to the number of months stated above.

Please detail the amount of time you have completed both inpatient and outpatient experiences that would enable us to

determine your eligibility. This information must be completed on the application.

ClerkshipsInpatientOutpatientTotal

Please use double digits (i.e. 01, 02 or 10, 11, 12)

Medicine weeks weeks weeks

Surgery weeks weeks weeks

Ob/Gyn weeks weeks weeks

Psychiatry weeks weeks weeks

Pediatrics weeks weeks weeks

Family Medicine weeks weeks weeks

Choices and alternatives for electives at the University of Chicago should be chosen from the courses listed on the web: https://duke.bsd.uchicago.edu/PSOMCourseCatalog/ . A course number must be entered, not just the course name. Please note that international medical students are only eligible for electives in their faculty sponsor’s department and that take place at UCM, not NorthShore or other affiliated sites.

Number of Months Requested: 1 month 2 months

Note: Students are limited to one-month electives unless from Partner Institutions.

1st choice: Course Name # Course # Start & End Date to

2nd choice: Course Name # Course # Start & End Date to

Have you previously participated in elective course work at the University of Chicago? Yes No If Yes: MonthYear

Please explain why you are interested in enrolling in a Pritzker elective (should not exceed 1500 words):

SECTION 2 – UCHICAGO FACULTY SPONSOR INFORMATION

Faculty Sponsor Name (LAST Name, FIRST Name) Department Title

Current Address with City/State/Zip Code

Current/Best Email Address Best Phone (No dashes)

SECTION 3 – ACADEMIC INFORMATION

Medical School Name

Address City State/Province Country

Postal Code Email Address

Telephone GPA

Highest Year of Medical School Completed Total Number of Years

Current Field of Study

City and Country of Birth

TOEFL Score (if applicable)

SECTION 4: - EMERGENCY CONTACT INFORMATION

Emergency Contact Name (LAST Name, FIRST Name) Relationship to Student

Current Address with City/State/Zip Code

Current/Best Email Address Best Phone (No dashes) Alternate phone

SECTION 5: - ADDITIONAL MATERIALS TO BE PROVIDED BY STUDENT

Student is required to produce the following items with the completed application, and will NOT be allowed to begin any rotations at the University of Chicago without these:

(1) Proof of personal health/hospitalization coverage (copy of insurance card) in effect while visiting student is rotating at the University of Chicago (in English). Please note that basic travel insurance without health coverage is insufficient. University policy requires:

a. Medical benefits of at least $50,000 per accident or illness

1. Repatriation of remains in the amount of $7,500
2. Expenses associated with the medical evacuation of the exchange visitor to his or her home country in the amount of $10,000
3. A deductible not to exceed $500 per accident or illness

Some examples of alternate health plans can be found at:

(2) Proof of current immunizations (SCHOOL CERTIFICATE OR LAB REPORT) attached (in English). Please see the additional immunization form on the requirements for visiting medical students found on the CGH website: cgh.uchicago.edu.

(3) Please see the “Visiting Medical Student Checklist” on the last page of this application for all additional required materials and submit all materials at once.

Student’s Photo Required

SECTION 4 - TO BE COMPLETED BY APPROPRIATE OFFICIAL AT VISITING STUDENT'S MEDICAL SCHOOL

Please circle the correct response (YES or NO) and complete each question:

(1) The medical student named above is in good standing at this institution, and

is authorized to take this elective for credit (must include school’s good standing letter). YES NO

(2) The student has the following ranking as a clinical student in this school:

_____ Outstanding Very Good Average

(3) Date upon which this student will be awarded his/her M.D. degree ______Month ______Year

(4) The student has proof of HIPAA Compliance, or plans to undergo HIPAA training upon arrival to Pritzker. YES NO

(5) The student will pay tuition at the home institution during the period indicated.YESNO

(6) The student has completed a course of study on universal precautions.YESNO

(7) The student needs an evaluation form submitted to his/her home institution after the elective.YES NO

Please fill out your contact information and sign below:

Name, and Address of School: ______

______

Phone Number:______

Email Contact:______

Name of Dean or School Official: (please print)______Date: ______

Signed: ______Title: ______

Official Seal of the Medical School must be affixed:

SECTION 7: - FOR PRITZKER OFFICE USE ONLY

Date of Receipt:______

Date Application Reviewed:______

Date Application to Program:______

Date Decision Received:______

Date Student Notified:______

When confirming arrangements with the student, please ask the student to check-in with the Visiting Student Coordinator in the Pritzker School of Medicine, 5841 S. Maryland Avenue, MC 7109, Room O-131, Chicago, Illinois 60637.

Approved By:

______

Signature Date

Visiting Medical Student Checklist

- To be completed by student -

Complete the following checklist and return the signed original with your application. Please do not send partially complete applications. Incomplete applications will not be processed. Applications must be received sixteen weeks before the start of your intended rotation.

I hereby attest that the above items are complete and represent the official documentation required for my candidacy as a visiting student to the University of Chicago Pritzker School of Medicine.

______

Signature of Student Date

Next Steps and Further Communication

(All communication will be sent via email. Due to the large volume of applications that we receive, please do not call to check the status of your visiting student application.)

• Confirming Receipt:An email confirmation of receipt of your application will be sent to you upon receipt.
• Scheduling Decision:You will receive email confirmation of acceptance or denial.
• Additional Instruction: If you are accepted, you will receive an email with further instructions about the rotation and

a brief orientation three to four days before you are scheduled to arrive.

• Departmental: You may also receive program-specific instructions via email in addition to communication

from the Pritzker School of Medicine.

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