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Yale School of Medicine

Visiting Student Elective Program

Student Information

Name: ________________________________________________________________________ Female/Male: ______

Last First Middle

Social Security Number and/or Passport Number: ___________________________Birth Date: ___/___/______ (mm/dd/yyyy)

Personal Mailing Address: ___________________________________________________________________________

Street Address City State Zip Code

Email: ____________________________________________________________________________________________

Telephone: (____) ______________________________________ Cell Phone: (____) _____________________________

Nationality: ________________________________________________________________________________________

Do you require housing during your elective rotation(s)? ________ Yes _________ No

Medical School InformationName of School: ____________________________________________________________________________________

Mailing Address: ____________________________________________________________________________________

Street Address City State Zip Code

Name of Dean: _____________________________________________________________________________________

Deans Office Telephone: (____) ________________________ Fax: (____) _____________________________________

Elective and Block Preference Academic Year 2012/2013Please select up to 2 elective choices:

(1) ____________________________ (2) ______________________________Four week block options: 06/18/2012 07/13/2012 01/02/2013 01/25/2013

07/16/2012 08/10/2012 01/28/2013 02/22/2013

I am choosing: 08/13/2012 09/07/2012 02/25/2013 03/22/2013

One (1) elective ___ 09/10/2012 10/05/2012 03/25/2013 04/19/2013

Two (2) electives ___ 10/08/2012 11/02/2012 04/22/2013 05/17/2013

11/05/2012 11/30/2012 05/20/2013 06/14/2013

Please select your preferred

block dates from the list of

options above: (1) _____________________________ (2) ______________________________

I have or will purchase health insurance and will provide proof of insurance before beginning the elective.

Student Signature: _____________________________________________ Month __________ Day ______ Year _____

To be completed by Applicants Medical School

This is to certify that the person named above is a student in good standing, has excellent English language skills sufficient to

complete a clinical elective, and will be in his/her final year of medical school at the time of the elective period listed above.

Students must provide their own personal health insurance.

Official Signature: _____________________________________________ Month __________ Day ______ Year _____

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Supplemental Form

For International Medical School Students Page 1

Name:

Have you spoken with or corresponded with a faculty member at Yale? Yes No

If yes, with whom?

Have you completed all basic science courses? Yes No

Have you completed a course of clerkship in:

1) Physical Diagnosis(physical examination and history taking)

2) Inpatient Internal Medicine3) Outpatient Internal Medicine

4) Neurology5) Obstetrics & Gynecology6) Pediatrics7) Psychiatry

When you participated in your clerkships, did you:

Did you take histories and perform physical exams?

Did you write up the above for inclusion in the patients record?

Did you present the patients clinical problem(s) to an attending physician?

Did you place your progress notes in the patients record?

:Knowledge of English:

WrittenSpoken

Last First Middle

Yes

Number

of

PatientsNo

Yes No

Excellent Good

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Have you had English as a primary language in a patient care setting?

Have you taken the TOEFL? (required when English is not the primary language)

Have you taken Step 1 United States Medical Licensing Exam?

Supplemental Form

For International Medical School Students Page 2

:

Please submit a personal statement describing your career goals, how this experience willhelp you achieve them, and whatyou have accomplished thus far in pursuit of those goals. Also include what cultural opportunities you will pursue duringyour stay. Please submit this statement in a separate document that is double-spaced and no more than one page

(approximately 250 words).

Yes No

DaScore

Your Signature

Official Signature

Dean of Your Medical School

Please Print or Type Deans Name

Certification (Seal)