UNIVERSITY OF GLASGOW

OVERSEAS
FACULTY OF MEDICINE
VISITING MEDICAL STUDENT ELECTIVE APPLICATION FORM
Forename: . Surname: ..
Address: ...
Passport
No...

Tel no:

E-mail: .

Age. D.O.B: .... Sex:: Country of Origin:.

Medical School: ..
Address
Length of Medical Course (years): ..
Year of Study at Present: ... Year of Study at Time of Proposed Elective: .
Completed Clinical Medical Education Prior to Proposed Elective:
..
..
Preferred Elective Topic:
First Choice: Dates:
Second Choice: Dates:
Third Choice: .. Dates:
Immunisation Details

N.B. Documentary evidence MUST be enclosed.

TETANUS vaccine
POLIO vaccine
TUBERCULOSIS vaccine
MUMPS/MEASLES/RUBELLA vaccine
DIPHTHERIA vaccine
VZ serological evidence of immunity
TB test e.g. Mantoux

YES

NO

DATE

RESULT

Please read the following statements carefully and delete where appropriate:
I have been immunised against Hepatitis B and have produced the following level of antibody: . IU/L".
or if this is not the case:
I have been immunised, have not produced antibody but have been investigated as regards my Hepatitis B
status and found not to be a Carrier.
NOTE: Only one elective at the University of Glasgow is permitted.
STUDENT'S SIGNATURE: .. DATE: ..

THE DEAN OF THE FACULTY OF MEDICINE, OR AN APPROPRIATE SENIOR FACULTY

OFFICER IS REQUESTED TO COMPLETE THIS SECTION OF THE APPLICATION FORM.
Name of student:
1. The above named student is presently in the ..... year of a .......year programme. The dates of
attendance for the final medical year are ................................... (day/month/year) to
.......................(day/month/year).
2. General assessment of the applicant's character and conduct:

3. Assessment of academic ability:

BELOW AVERAGE / AVERAGE / ABOVE AVERAGE
4. Assessment of clinical ability:
BELOW AVERAGE / AVERAGE / ABOVE AVERAGE
5. Details of clinical experience to date:

6. Students knowledge of English:

Spoken: .. Written:
7. Is there any further information which you think might be of assistance?
.
8. I support without reservation/with reservation the application from this student for the proposed
elective.
Signature:

Official Stamp of Medical School:

Position: .
Date: ..
Medical School: ..
E-mail address : .
Please return this form to Mrs. Sheila Le Vin, , Medical School, Wolfson Medical School Building, University of Glasgow,
Glasgow, G12 8QQ, Scotland, UK. Telephone: +44 -(0)- 141-330 8023, e-mail: Sheila.LeVin@glasgow.ac.uk