US Graduates Program Name: A University of Wisconsin Hospital and Clinics sponsored GME program Application Deadline: Thank you for your interest in Graduate Medical Education at the University of Wisconsin Hospital and Clinics. Here is checklist of items needed for your application to be considered complete. For students and graduates of non-lcme accredited medical schools (IMGs) please see the reverse side. UWHC Uniform Graduate Medical Education Application form for non-eras applicants (completely filled out and signed. CVs will not be accepted in lieu of the Application). You must sign and date the attestation form at the end of the application. Current and former Program Director(s) letter of recommendation (original letters, copies will not be accepted. All former Program directors must be included) An email or documented phone call between program directors is acceptable in lieu of requirement. USMLE scores or NBOME (COMLEX scores). If we can verify full medical licensure that required Step III completion via the AMA profile, this requirement will be waived. Other letters of recommendation (minimum of 2 our program requires accepted.) Copies will be Medical School Transcript. If we can verify your graduation via the AMA profile, this requirement will be waived. Medical School Letter of Evaluation (formerly known as the Dean s letter). Copies will be accepted. Personal Statement. Please write a current one for this application. Please return all materials to: Program Name Address Attention: UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 1 of 8
International Medical Graduates Program Name: A University of Wisconsin Hospital and Clinics sponsored GME program Application Deadline: Thank you for your interest in Graduate Medical Education at the University of Wisconsin Hospital and Clinics. Here is checklist of items needed for your application to be considered complete. (For students and graduates of LCME accredited medical schools (US Graduates) please see the reverse page. UWHC Uniform Graduate Medical Education Application form for non-eras applicants (completely filled out and signed. CVs will not be accepted in lieu of the Application). You must sign and date the attestation form at the end of the application. ECFMG certificate (must be complete prior to start of training). Current and former Program Director(s) letter of recommendation (original letters, copies will not be accepted. All former Program directors must be included) IMG s must have at least one letter from a program director certifying one year of US clinical experience. USMLE scores or NBOME (COMLEX scores) ECFMG is OK. Other letters of recommendation (minimum of 2 our program requires accepted.) Copies will be Medical School Transcript (from ECFMG) Medical School Letter of Evaluation (if available, in English) Copies will be accepted. Personal Statement. Please write a current one for this application. Please return all materials to: Program Name Address Attention: UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 2 of 8
University of Wisconsin Request for Letter of Recommendation For Non-ERAS Application Process Date: Letter Writer: Applicant Name: Thank you for agreeing to write a letter of recommendation in support of my application. This sheet explains the special procedures needed to prepare a letter for the University of Wisconsin Hospital and Clinics residency programs. Please send the letter of recommendation to the designated department using the following format. Letters from Program directors must be signed originals. Letters from faculty other than Program directors may be a copy. 1. Address the letter to Dear Program Director or Department Chair. (I would be happy to provide you a list of programs to which I am applying). Include in the letter that I have or have not waived my right to see this recommendation, as indicated below. 2. Write your letter on letterhead. 3. Please print your letter to be placed in my file. 4. Attach this sheet to your letter before sending it, to help my designated department to identify your letter with my file. Thank you in supporting my application. (I waive) (I do not waive) my right to see this letter. If waived is checked, I waive my right to see this letter. I acknowledge that this letter is for the specific purpose of supporting my application for an Internship, Residency or Fellowship. SIGNED: Mailing Address: Name: Department: Address: City: ST: ZIP: Phone: Email: UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 3 of 8
UWHC Graduate Medical Education Application (for non-eras applicants) This worksheet may be printed and used to begin completing your application non-electronically. If you wish to submit a nonelectronic copy it must be typed or completely legible. All required fields are marked with an asterisk (*). Please note, however, that some of these fields are required only in certain circumstances. For example, if you state that you did earn or expect to receive a degree from an institution, you will be required to enter what that degree is. (PLEASE PRINT OR TYPE WHEN FILLING OUT THE APPLICATION). Program Applying For: Program Start Date: Anticipated Training Year: Profile First Name: * Middle Name: Last Name: * Suffix: Previous Last Name: Degree: MD MD, PhD DO MBBS MBchS Current Address: Street Address: * City: * State/Province: * Post Code: * Country: * Preferred Phone:_( ) * Alternate Phone:_( ) * Mobile: _( ) Pager: _( ) Fax: ( ) Contact Email: * Permanent Mailing Address: Street Address: * City : * State/Province: * Post Code: * Country: * Phone: _( ) * Social Security Number: SSN: * NPI: Canadian SIN: Match Participation: I am applying for position outside the match. I am participating in the NRMP Main Match. I am participating in the NRMP Specialties Match. I am participating in a match as part of a couple AND I wish to notify programs of this. San Francisco Matching Service AUA Number: (required for Urology Match Participants only) Other Specialties Partner is applying to: Partner s Name: UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 4 of 8
Military Are you committed to fulfill U.S. Military active duty service obligations/deferments? * No Yes If Yes: Years: Branch: Do you have any other service obligations? (i.e. Military Reserves or Public Health/State programs) * No Yes: Description: Work Eligibility Do you meet one of the following criteria? Yes No 1. US citizenship 2. Permanent legal residency status in the US (green card) 3. Eligible to hold a J-1 Clinical Visa sponsored by ECFMG. Note: The UWHC will not sponsor H-1 (temporary worker) visas. Other legal documents authorizing work In the United States will be reviewed by the GME office. Foreign Medical Graduates: Are you certified by the Educational Commission for Foreign Medical Graduates? (attach a copy of the ECFMG certificate). Check all that apply. No Yes Month: Year: USMLE/ECFMG ID: ECFMG certificate is attached with the application * (Label as 2-a) Miscellaneous Foreign Medical Graduates applying for Residency Positions: To be answered by Foreign Medical Graduates only. See www.ecfmg.org/eras for information and mailing instructions. Will you provide a MSPE to the UWHC? * Yes No Will you or your medical school provide a transcript to UWHC? * Yes No **Please attach copies and a translation if not in English Non-Medical Education For each non-medical educational institution you have attended, please provide the requested information. You may create as many entries as needed on the electronic form or add an additional page. None #1 Institution: * Location: * Education Type: * Undergraduate Graduate Other Major: * Degree expected or earned: * Yes No Degree: Degree Month: Degree Year: Dates of Attendance: From To * UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 5 of 8
#2 Institution: * Location: * Education Type: * Undergraduate Graduate Other Major: * Degree expected or earned: * Yes No Degree: Degree Month: Degree Year: Dates of Attendance: From To * Refer to attachment for additional information. (Reference as 3-a, 3-b etc.) Medical Education For each medical school you have attended, please provide the requested information. You may create as many entries as needed on an additional page. #1 Country: * Institution: * Clinical Campus: * * only available for select US Medical Schools Degree expected or earned: * Yes No Degree: Degree Month: Degree Year: * Dates of Attendance: From To * #2 Country: * Institution: * Clinical Campus: * * only available for select US Medical Schools Degree expected or earned: * Yes No Degree: Degree Month: Degree Year: * Dates of Attendance: From To * Refer to attachment for additional information. (Reference as 3-c) Previous Residency/Fellowship Training For each internship, residency, or fellowship position you have held or currently are in, regardless of the amount of time spent there, please provide the requested information. This worksheet has space for you to make 3 entries. You may create as many entries as needed on an additional page. None #1 Specialty: * Type of Training: Internship Residency Fellowship * Dates of Residency/Fellowship: From: To: Month/year Month/year Institution/Program: * City: * State/Province: * Country: * Program Director: * Supervisor: * UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 6 of 8
#2 Specialty: * Type of Training: Internship Residency Fellowship * Dates of Residency/Fellowship: From: To: Month/year Month/year Institution/Program: * City: * State/Province: * Country: * Program Director: * Supervisor: #3 Specialty: * Type of Training: Internship Residency Fellowship * Dates of Residency/Fellowship: From: To: Month/year Month/year Institution/Program: * City: * State/Province: * Country: * Program Director: * Supervisor: Chief Resident (only relevant for Fellowship Applicants) Dates of Attendance Residency/Fellowship: From To Reason for Leaving: Was your medical education/training extended or interrupted? Please explain any gaps of 3 or more months during your medical education and /or residency training. * No No Response Yes Reason: Refer to attachment for additional information. (Reference as 4-a) State Licenses For each state license you have, please provide the requested information. This worksheet has space for you to make 2 entries. None #1 State: * License Type: Full Temporary or Limited Inactive License Number: * Expiration Month * Expiration Year * (License number, expiration month and expiration year is only required if license type is Full ) #2 State: * License Type: Full Temporary or Limited Inactive License Number: * Expiration Month * Expiration Year * (License number, expiration month and expiration year is only required if license type is Full ) Refer to attachment for additional licenses. (Reference as 4-b) Medical Licensure Has your medical license ever been suspended/revoked/voluntarily terminated? No Yes Reason: UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 7 of 8
Have you ever been named in a malpractice case? * No Yes Reason: Reason: Malpractice Claims History is attached (Reference as 5-a) Is there anything in your past history that would limit your ability to be licensed or to receive hospital privileges? * No Yes Reason Have you ever been convicted of a felony? * No Yes Reason: Are you Board Certified? Yes No 1. Board Name Expiration: 2. Board Name Expiration: 3. Board Name Expiration: DEA Registration: Number * if applicable Expiration Month: Expiration Year: Examinations For each examination you have taken, please provide the requested information. This worksheet has space for you to make 4 entries. (Osteopathic applicants: include the exams (COMLEX or USMLE) that lead to the medical licensure route you intend to pursue). None Exam #1: 1 st attempt Passed Failed Month: * Year: * 2nd attempt Passed Failed Month: * Year: * USMLE Step I NBME I Awaiting results from USMLE Step II CK NBME II Will take on USMLE Step II CS NBME III Incomplete USMLE Step III COMLEX Level I COMLEX Level II COMLEX Level III Exam #2: 1 st attempt Passed Failed Month: * Year: * 2nd attempt Passed Failed Month: * Year: * USMLE Step I NBME I Awaiting results from USMLE Step II CK NBME II Will take on USMLE Step II CS NBME III Incomplete USMLE Step III COMLEX Level I COMLEX Level II COMLEX Level III UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 8 of 8
Exam #3: 1 st attempt Passed Failed Month: * Year: * 2nd attempt Passed Failed Month: * Year: * USMLE Step I NBME I Awaiting results from USMLE Step II CK NBME II Will take on USMLE Step II CS NBME III Incomplete USMLE Step III COMLEX Level I COMLEX Level II COMLEX Level III Exam #4: 1 st attempt Passed Failed Month: * Year: * 2nd attempt Passed Failed Month: * Year: * USMLE Step I NBME I Awaiting results from USMLE Step II CK NBME II Will take on USMLE Step II CS NBME III Incomplete USMLE Step III COMLEX Level I COMLEX Level II COMLEX Level III Cardiopulmonary Resuscitation & Other Life Saving Intervention Certification I am CPR / BLS (Cardiopulmonary Resuscitation) certified in the U.S.A I am ACLS (Advanced Cardiac Life Support) certified in the U.S.A. I am PALS (Pediatric Advanced Life Support) certified in the U.S.A. I am ATLS (Advanced Trauma Life Support) certified in the U.S.A. Expiration Date: (Month/year) Expiration Date: (Month/year) Expiration Date: (Month/year) Expiration Date: (Month/year) Experience(s) For each non-residency relevant work, research, and volunteer experience/position you have had, please provide the requested information. Include non-residency clinical and teaching experience as work experiences, and include all unpaid extra-curricular activities and committees you have served on as volunteer experiences. This worksheet has space for you to make 2 entries. You may create as many entries as needed on an additional page. None #1 Type: Work Research Volunteer Organization: * Position: * Supervisor: * Average Hours Per Week: Dates of Experience: From To * Description: Reason for leaving: UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 9 of 8
#2 Type: Work Research Volunteer Organization: * Position: * Supervisor: * Average Hours Per Week: Dates of Experience: From To * Description: Reason for leaving: Refer to attachment for additional information. (Reference as 7-a) Publications (Use also for Poster Sessions/Abstracts/Invited National or Regional Presentations) For each publication/presentation you have had, please provide the requested information. This worksheet has space for you to make 3 entries. You may create as many entries as needed on an additional page. None #1 Title: * Authors/Presenters: * Publication/Organization: * Month: Year: Volume: Pages: #2 Title: * Authors/Presenters: * Publication/Organization: * Month: Year: Volume: Pages: #3 Title: * Authors/Presenters: * Publication/Organization: * Month: Year: Volume: Pages: Refer to attachment for additional publications. (Reference as 7-b) All applicants: Language Fluency (Other than English): Hobbies and Interests: UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 10 of 8
Medical School Awards: Other Accomplishments: Membership in Honorary/Professional Societies: Are you able to carry out the responsibilities of a resident in the specialties and at the specific training program to which you are applying including the functional requirements, cognitive requirements, interpersonal and communication requirements, and attendance requirements with or without reasonable accommodations? * Yes No Response No, Limiting Aspects (please explain) Attestation Background Disclosure and Check. I understand that I must fill out a Wisconsin Background Information Disclosure (BID) form and that a background check will be performed as required by state law. The BID form is considered part of this application. I understand that I will not be employed or will be removed from employment if the employer discovers certain crimes or offenses. If I am assigned to work at another site that requires a BID form and check, I authorize UWHC to release this information to the other site. Health Screening and Drug Testing. I understand that any offer of employment is contingent on successful completion of a pre-employment physical which will include mandatory pre-employment drug testing and which also may include alcohol testing. I understand the UWHC will rescind my offer of employment if I do not comply with all procedures for preemployment drug testing. I understand that I should consider whether I wish to provide notice of my intent to end my employment with my current employer prior to successfully passing the UWHC s pre-employment drug testing. Identity and Work Authorization: Federal law requires UWHC to verify the identity and work authorization of each successful candidate. Any offer of employment is contingent upon this verification. Social Security Number: I understand that UWHC will use the Social Security Administration s Verification Service (EVS) to verify my social security number after hire, if I am hired. Authorization of Release of Information. I authorize the release of information to UWHC regarding my work history, education, licensing/certification and performance. I understand that any offer of employment is contingent upon UWHC obtaining satisfactory responses to inquires and hold harmless the companies, schools and persons from liability. Certification of Accuracy and Completeness. I certify that all of the information provided in this application is true and complete to the best of my knowledge. I acknowledge that I may be required to verify information prior to appointment and that any omitted, false or misleading information may disqualify me from employment consideration and may be grounds for termination from employment. Signed: Date: Printed Name: Please print off this page. Sign, date, and scan or fax back to program applying for. UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 11 of 8
Additional Required Questions Applicant Name: Program Name: This sheet will be removed before decision makers decide who to interview. Information below may be discussed during the interview. Felony Question: Have you ever been convicted of a felony? Yes No ** Section 111.321, Wis. Stats., generally prohibits employment discrimination on the basis of arrest or conviction record. An employer may only refuse to hire a qualified applicant because of a conviction record for an offense that is substantially related to the circumstances of a particular job. The legislature has determined that certain convictions are substantially related to employment in child and adult care giving programs regulated by the Department of Health and Family Services. Work Eligibility: * Which of the following criteria do you meet? US Citizen Permanent Resident Eligible to hold a J-1 Clinical Visa sponsored by ECFMG Other legal documents authorizing work in the US. Note: The UWHC will not sponsor H-1 (temporary worker) visas. Other legal documents authorizing work In the United States will be reviewed by the GME office. Additional Comments: Current Visa Type: B-1 - Temporary visitor for business B-2 - Temporary visitor for pleasure F-1 - Academic student F-2 - Spouse or child of F-1 TN - NAFTA trade visa for Canadians and Mexicans H-1 - Temporary worker TN - NAFTA trade visa for Canadians and Mexicans H-1B - Specialty occupation, DoD worker, etc. Diplomatic Service H-2B - Temporary worker- skilled and unskilled Immigrant H-4 - Spouse or child of H-1, H-2, H-3 EAD-Employment Authorization J-1 - Visa for exchange visitor Expiration date: * J-2 - Spouse or child of J-1 O-1 - Extraordinary ability in sciences, arts, education, business, or athletics Other UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 12 of 8
Information below will only be used after you have been offered a position in order to complete the hiring process. This information will not be viewed during the interview process. Marital Status: Married Single Gender: Female Male Birth: Birth Date: * Birth City: Birth Country: Birth State: Racial and Ethnic Group: This section allows entries for race self-identification. You may select one or more races. Specify "other" if your race is not listed. You may create as many entries as needed. Black (not of Hispanic Origin): All persons having origins from any of the black racial groups. Asian or Pacific Islanders: All persons having origins from any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, Samoa, and India. American Indian or Alaskan Native: All persons having origins of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Hispanic: All persons from Mexican, Puerto Rican, Cuban, Central or South American, Iberian Peninsula, or other Spanish culture or Origin, regardless of race. White (not of Hispanic Origin): All persons having origins from any of the original peoples of Europe, North Africa, and the Middle East. Unknown Other: UWHC Uniform Graduate Medical Education Application September 2010 (for non-eras applicants) 13 of 8