Elective Application for Visiting Medical Students 2011-2012

Office of Curricular Affairs 1402 S. Grand Blvd., LRC 101 St. Louis, MO 63104 Phone: (314) 977-8077 School of Medicine

*Applications received prior to May 1st will not be considered. Section I: To be completed by the applicant (Please type or print clearly)

Applicant’s Name: _________________________________________________________________________________

(First, Middle, Last)

Last 4 digits of SSN# XXX-XX-___________ Date of Birth: ___/____/_____ Gender: Male _____ Female ____ (Please mark one) E-Mail Address: ____________________________________ Expected Graduation Date: ____________________ Mailing Address: _____________________________________________________________________________________

Street, City, State, Zip Telephone Number: (_____) ______________________ Please circle: Home or Cell

ELECTIVES DESIRED (No exceptions or extensions to dates on table of period codes) 1._______________________________________________________ __________ to __________ Primary Request Course Number Date Date 2._______________________________________________________ __________ to __________ Alternate Request Course Number Date Date 3._______________________________________________________ __________ to __________ Alternate Request Course Number Date Date

Section II: To be completed by the Dean (or designee) of Student’s School

This school is accredited by the LCME or by the AOA

Yes No

The above named student is in good academic standing at this school and has my approval to participate in the elective(s) listed above.

Yes No

On the dates requested for participation, this student will be in his/her final year of medical school, and will have successfully completed all required junior level clerkships.

Yes

No

This student will have personal health and hospitalization insurance in effect through his/her home school during the above mentioned dates.

Yes No

This student has completed HIPPAA training.

Yes No

This student has completed a criminal background check that did not disclose information with relevance to patient care responsibilities.

Yes No

Does your school require a drug screening test? If yes, you must provide proof of passing the test. If No, you must take a test and supply the results with this application.

Yes No

This student has met your school’s immunization requirements.

Yes No

This student is covered by Liability, Malpractice while away from our school. SLU requires minimal coverage limits of $2,000,000 (2 million). (Please enclose proof of insurance)

Yes

No

__________________________________________ __________________________________________________________ Signature of School Official Name of School __________________________________________ __________________________________________________________ Name and Title Mailing Address __________________________________________ __________________________________________________________ Date City, State, Zip Code

__________________

Place School Seal Here

(____) ______ Telephone Number

Section III: To be completed by the Office of Curricular Affairs Section IIII is for SLU SOM use only. The student □ is approved □ is not approved for the elective indicated below. Reason Not Approved: ________________________________________________________________________________________________ Elective: ______________________________________________ Term: _________________________ Dates: ___________________________________________ Approved by _________________________________________ Department: __________________________________ Phone Number: ________________________________________ Date Approved: ______________________________________ Student Notified: ______________________________________

Banner ID: ________________________________________