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: ________________________________________
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