Students must adhere to Brown s elective calendar of dates. No exceptions will be made. Do not contact the hospitals directly.

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1 THE WARREN ALPERT MEDICAL SCHOOL OF BROWN UNIVERSITY VISITING STUDENTS FROM U.S. & CANADIAN MEDICALSCHOOLS Clinical Elective Application Last Name, First Name, Middle Name: Date: Mailing Address: Address: Home Medical School: Telephone Number: Gender: Date of Birth: Year of Graduation from Medical School: I (request) (do not request) housing State of Residence: Students must adhere to Brown s elective calendar of dates. No exceptions will be made. Do not contact the hospitals directly. Elective Choices: Elective Code Location Elective Title Dates of Elective I will accept the following alternative electives and/or dates: Elective Code Location Elective Title Dates of Elective

2 STATEMENT OF DEAN FROM HOME MEDICAL SCHOOL The medical student named above is in good standing at this institution, is in the final year of a year program, and has approval to take the elective. Student [will] [will not] pay tuition at our school during the period indicated. Malpractice insurance [does] [does not] cover the student while taking approved work at an outside institution. Coverage amounts are equal to at least $1 million per occurrence, $3 million aggregate. Student [is] [is not] covered by student health insurance. Student [has] [has not] attended an educational session on the prevention of bloodborne and airborne pathogen infection in compliance with OSHA regulations. Student [has] [has not] been mask fit on a TecnolPFR95 (small or regular) or 3M 1860 (small or regular) within the last 12 months. At the conclusion of the course an evaluation report [is] [is not] required. Please note that The Warren Alpert Medical School does not complete other schools evaluation forms. Once the evaluation has been submitted via OASIS, our online evaluation system, the student may download a copy and turn it in to their school accordingly. Printed Name: Title: Signature: Date: (School Seal) Only original signature and seal accepted.

3 STATEMENT OF VISITING MEDICAL STUDENT I am aware that acceptance as a visiting medical student carries no implication concerning formal admission to or matriculation at The Warren Alpert Medical School of Brown University. Evaluation of my performance while studying at The Warren Alpert Medical School is based on the same criteria as those used to evaluate matriculated medical students at Brown. As such, only the Warren Alpert Medical School Clinical Evaluation Form will be provided at the end of the approved elective period. A completed Brown Proof of Immunization form is attached to this application. I understand that I am required to pay a non refundable application fee of $ per elective, by check payable to BROWN UNIVERSITY, upon submission of my completed application packet. I also understand that acceptance for an elective is made on a first-come, first-served basis. Priority in scheduling electives is given to Brown students and in rare situations, my assigned elective may be changed up to two weeks before the start date. In this eventuality, every effort will be made to provide me with another elective of my choice. I will be notified of the change and no refund will be given in this circumstance. Printed Name: Date: Signature: Address:_ ALL APPLICATIONS MUST BE COMPLETE AND INCLUDED IN ONE PACKAGE OR THEY WILL BE RETURNED. NO EXCEPTIONS. DUE TO SHEAR VOLUME OF APPLICATIONS, WE CANNOT HOLD APPLICATIONS FOR SUPPLEMENTAL OR MISSING MATERIALS. Please return the following: 1) The original completed and signed application form with school seal; 2) List of clerkships you have completed; 3) Please include a Letter of Good Standing from your home institution confirming the following: a. Completion of training in OSHA Safety Measures and Infection Control Precautions (include expiration date) b. Health Insurance coverage; c. Malpractice Insurance coverage; d. Completion of HIPAA certification with expiration date; e. Certification of Respiratory Mask Fit Testing with size and expiration date ** If the any of the above items are not included in your Letter of Good Standing, please provide separate documents as confirmation.

4 8) The original completed proof of immunization form. Please take note of this institution s PPD requirements as they may be different from your home school. 9) The application fee. Please be aware, if your application fee is returned to this institution s Accounting Office due to insufficient funds, you will be immediately cancelled from your scheduled rotation. 10) Two mini photos 11) Copy of CV and Transcript 12) Proof of USMLE Step 1 Score Please mail the packet to: Linda A. Conte, Clerkship Assistant The Warren Alpert Medical School of Brown University 222 Richmond Street, Box G-M265 Providence, RI 02912

5 Detailed list of all full-time hands-on clerkship experiences you will have completed before participating in clerkships at Alpert Medical School Title of Clerkship Specialty (Medicine, Pediatrics, etc.) Duration (in weeks) Was this a handson, full-time experience? If not, explain. Student Name: Date:

6 PROOF OF IMMUNIZATION FORM VISITING US/CANADIAN MEDICAL STUDENTS Please use this form and do not send separate proof of immunizations Name of Student: Name of Medical School: INFLUENZA: I will provide proof that I have been vaccinated against influenza within 12 months of arrival at Brown. Tdap: I will provide proof (month/day/year) that I have been vaccinated with Tdap (Tetanus, Diphtheria, Pertussis) within the last 10 years. HEPATITIS B: I will provide proof of THREE doses of Hepatitis B vaccine (month/day/year) or serologic evidence of Hepatitis B immunity. MEASLES: I will provide proof (month/day/year) that I have been vaccinated with TWO doses of live virus measles (rubeola) vaccine administered at least 28 days apart after my first birthday or positive immunity titers. MUMPS: I will provide proof (month/day/year) that I have been vaccinated with live virus mumps vaccine administered on or after my first birthday, or positive immunity titers. RUBELLA: I will provide proof (month/day/year) that I have been vaccinated with rubella vaccine administered on or after my first birthday or positive immunity titers. VARICELLA: I will provide proof (month/day/year) that I have been vaccinated with TWO doses of varicella vaccine administered 4 8 weeks apart or serologic evidence of varicella immunity. TB SCREENING: I will provide proof of TWO Tuberculosis Skin tests (PPD) at least 2 weeks apart, (3wks. max.) done within 6 months of arrival at Brown. If I have a non negative result to the test, I will provide documentation of a chest x ray and if indicated, prophylaxis therapy. Immunization Documentation Influenza (shot) within 12 months of arrival at Brown Tdap Booster (within last 10 years) Hepatitis B three doses Measles/Mumps/Rubella Measles (single dose) Mumps (single dose) Rubella (single dose) PPD (*two skins tests at least 2 weeks apart, within 6 months of arrival at Brown) To be completed by student health service representative Month/Day/Year Month/Day/Year Month/Day/Year Placement date 1: Read date 1: Results (in mm) Placement date 2: Read date 2: Results (in mm) Varicella (shots or titer) Student Health Service Representative s Signature, type name and title. Date:_

7 Clerkship Calendar 5/06/13 7/26/13 Quarter 1 5/06/13 6/14/13 6/17/13 7/26/13 5/06/13 5/31/13 6/03/13 6/28/13 7/01/13 7/26/13 *** VACATION: 7/27/13 8/04/13 *** 8/05/13 10/25/13 Quarter 2 8/05/13 9/13/13 9/16/13 10/25/13 8/05/13 8/30/13 9/02/13 9/27/13 09/30/13 10/25/13 *** VACATION: 10/26/13 11/03/13 *** 11/04/13 1/31/14 Quarter 3 11/04/13 12/13/13 V * 12/16/13 1/31/14 11/04/ /29/1 12/2/13 *week off 1/3/14 1/06/14 1/31/14 QUARTER 3 VACATION: 12/21/13 01/05/14 (falls between the six week blocks in qtr. 3)

8 Clerkship Calendar 2/03/14 04/25/14 Quarter 4 2/03/14 3/14/14 3/17/14 04/25/14 2/03/14 2/28/14 3/03/14 3/28/14 3/31/14 4/25/14 *** VACATION: 4/26/14 5/04/14 *** 5/05/14 7/25/14 Quarter 5 5/05/14 6/13/14 6/16/14 7/25/14 5/05/14 5/30/14 6/02/14 6/27/14 6/30/14 7/25/14 *** VACATION: 7/26/14-8/3/14 *** 8/04/14 10/24/14 Quarter 6 8/04/14 9/12/14 9/15/14 10/24/14 8/04/14 08/29/14 9/01/14 9/26/14 09/29/14 10/24/14 *** VACATION: 10/25/14-11/2/14 ***

9 Clerkship Calendar 11/03/14 1/30/15 Quarter 7 11/03/14 12/12/14 *V 12/15/14 1/30/15 11/03/14 11/28/14 12/1/14 *week off 1/02/15 01/05/15 1/30/15 VACATION: 12/20/14 01/04/15 12/20/14 01/04/15 (falls into the six week block in qtr. 3b/7b) 2/02/15 4/24/15 Quarter 8 2/02/15 3/14/15 3/17/15 4/24/15 2/02/15 2/27/15 3/02/15 3/27/15 3/30/15 4/24/15