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) visiting.pritzker@bsd.uchicago.edu

Note to applicants: A complete application does NOT guarantee acceptance or admission. Please do not make travel arrangements until you have received enrollement 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 Medical School (where currently enrolled)

Current Address with City/State/Zip Code

Current/Best Email Address

Best Phone (No dashes)

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. Clerkships Inpatient Outpatient Total 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://aaa-uruk04.cri.uchicago.edu/PSOMCourseCatalog/browse/CoursesOpenToVisitingStudents.aspx?year=current. Both course name and number should be entered. 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. Course selection preferences and Note: Students are limited to one-month electives. Electives usually start on the first of the month. 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: Month

Year

2

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

SECTION 2 – UCHICAGO FACULTY SPONSOR INFORMATION – required for non-partner s i tes 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 (Required for students studying in countries outside of the British Commonwealth) Subscores: Reading

Listening

Speaking

Writing

Total Score 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

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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) CV in English (2) Letter from Dean of your home institution/medical school that states you are: 1) currently enrolled and is in good academic

standing; 2) Has permission to leave (state proposed time frame); 3) Will return to home institution upon completion of elective

(3) Official transcript (4) Letter of support from faculty sponsor at UChicago (if not from a partner institution)

Upon acceptance into the elective program, students must provide additional documentation within 30 days of elective approval:

(1) Copy of Passport and Visa (2) 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 b. Repatriation of remains in the amount of $7,500 c. Expenses associated with the medical evacuation of the exchange visitor to his or her home country in the

amount of $10,000 d. A deductible not to exceed $500 per accident or illness

Some examples of alternate health plans can be found at: http://www.isoa.org/compass_main.aspx (3) 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.

(4) Official TOEFL Score report (if from a country outside of the British Commonwealth)

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. YES NO (6) The student has completed a course of study on universal precautions. YES NO (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:

4

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

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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.

Required On Date of Application Completed Completed Pritzker/CGH Visiting Medical Student Application Curriculum vitae (CV) in English Letter of Good Standing from the Dean of your school Official Transcript in English If from a non-partner institution, letter from the UChicago Faculty Sponsor Proof of HIPAA Compliance (This can also be completed upon arrival at Pritzker)

Due within 30 days after elective approval Copy of Visa and Passport Student Health Form and proof of immunization (cgh.uchicago.edu/page/visiting-medical-students) Proof of Personal Health Insurance In English TOEFL score if not from a country part of the British commonwealth

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 your application will be sent to you within 3 business days of receipt. • Scheduling Decision: You will receive email confirmation of acceptance or denial. • Additional Instructions: If you are accepted, you will be asked to submit the documentation detailed above.

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.

Application fees: Elective enrollment fees are due at the time of application. The fee will be refunded to students that are not placed in a Pritzker elective within 60 days of application. Once accepted into the program, refunds will not be issued to students who withdraw from the program.