NON-EMPLOYEE ID # REQUEST FORM for CONTRACTORS/TRAVELERS/PHYSICIANS

Today’s Date: FOR HR USE ONLY

Submitter: Lyndie Pfannkuche emPath ID#:

Submitter phone no: 760-837-8248 Orientation Date:

Comments: MED Student Created by:

PERSONAL INFORMATION

Last name: First: Middle: Nickname:

Address:

Social Security no.: Contact phone no.: Birth date: Sex:

POSITION INFORMATION

Start Date: [Date]

Cost Center/Department: 988-8270 / Graduate Medical Education

Job Code/Title: 5201/ Medical Student

ACCESS BADGE

Dept. and/or building access required:

Mirror the access of (name):

Security Card Acknowledgement

I understand that this security access card is used to gain access to secured areas on the campus and that if it is lost or misplaces, I am to immediately report it to the Human Resources Department (ext. 8500) or the Security Department (ext. 8200).

I also understand that this security access card must be returned to Eisenhower Medical Center upon termination or end of assignment.

Contractor Signature:

Security Name Signature: Date:

SIGNATURE

Director’s Name: Sandra Gonzales

Director’s signature: Date:

C:\Users\Cheri\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\LTAYJW1G\Access Badge Request Med Students.doc

Access Badge Request Eisenhower Medical Center

Security card access request: New X (Circle reason for replacement: lost or defective) Bridge Access ______

Name: Dept.: Graduate Medical Education Title: Medical Student Emp ID# Cost Center #:_988-8270__________ Date__________ Ext.__________ Dept. Director/Manager Name: Sandra Gonzales Signature: ______________________ (Name and signature required for security access card) Security Name: ___________________ _______Signature:_________________________________ Ext:_________ (Security Supervisor/Director signature required for all security access cards) Note: Photocopied signature will not be accepted.

Access Badge Type (check one) EMC Employee Volunteer Physician Physician Staff Eisenhower Imaging Center Traveler X Student Contractor ___________________ Company Name ___ _____ Vendor _______________________ Company Name Other: SECURITY CARD # ISSUED CANCEL CARD # (if any)

Security Card Acknowledgement I understand that this security access card is used to gain access to secured areas on the campus and that if it is lost or misplaced; I am to immediately report it to the Human Resources Department (ext. 8500) or the Security Department (ext.8200). I also understand that this security access card must be returned to Eisenhower Medical Center upon termination or end of assignment. Print Name and Signature Date

HR/Generalist:________

For HR Use Only:

Entered in Empath Y/N

All requirements met? Y/N

Please list Dept. and/or Building

access required: As below

Mirror the access of: (name)

CLERKSHIP/ELECTIVE APPLICATION

1. Please complete Section I of the application. Return the application to

the Eisenhower Medical Center Clerkship Coordinator along with your:

CV

Transcripts

USMLE Step score________ or COMLEX Step score_________

2. When approved, the Eisenhower Medical Center Clerkship Coordinator

will send an email confirmation to the medical school and applicant.

3. Bring the following documentation: picture ID, school ID, and

immunization records. You will be drug tested. If you are on ANY

medications which show up in a urine screening, please bring

prescription and ordering physician’s name and contact information.

Desired Elective/Clerkship: Check One

____ Ambulatory internal Medicine Elective

_____ Cardiology Elective

_____ Emergency Medicine Elective

_____ PM&R

_____ Family Medicine Clerkship

_____ Geriatrics Elective

_____ HIV Elective

_____ Nephrology Elective

_____ PM&R (Rehabilitation Medicine) Elective

_____ Sports Medicine Elective

_____ Psychiatry TMS Elective

4. Email Clerkship application to clerkship@emc.org

APPLICATION FOR CLERKSHIP

I hereby apply for clinical clerkship experience at the Eisenhower Medical Center, Rancho Mirage,

California. I would like to begin this 2 week or 4 week (select one) on: (fill in dates)

(1st choice) ______________, (2nd choice) _______________, or (3rd choice) ________________ .

This clerkship is a/an (check): _________ requirement _______________ elective

____________________________________________________ _________________________

Signature of Medical Student Date

Section I: To be completed by medical student (Please print)

Student’s Name: _______________________________________________________________________

Address__________________________________________________________________________

Email Address: ________________________________________________________________________

Mobile Phone #: _______________________________________________________________________

Medical School: ________________________________________________________________________

Medical School Address: _________________________________________________________________

Medical School Year: _______________________________________

Languages/fluency: ____________________________________________________________________

Premedical School, dates, degree: _________________________________________________________

Name of Medical School Dean/phone #:____________________________________________________

Emergency contact name/phone #: ________________________________________________________

Current Career Goals: __________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________