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 Information

Name of School: ____________________________________________________________________________________

Mailing Address: ____________________________________________________________________________________
Street Address
City
State
Zip Code
Name of Dean: _____________________________________________________________________________________
Deans Office Telephone: (____) ________________________ Fax: (____) _____________________________________

Elective and Block Preference Academic Year 2012/2013

Please select up to 2 elective choices:
Four week block options:
I am choosing:
One (1) elective ___
Two (2) electives ___
Please select your preferred
block dates from the list of
options above:

(1) ____________________________ (2) ______________________________

06/18/2012 07/13/2012
07/16/2012 08/10/2012
08/13/2012 09/07/2012
09/10/2012 10/05/2012
10/08/2012 11/02/2012
11/05/2012 11/30/2012

01/02/2013 01/25/2013
01/28/2013 02/22/2013
02/25/2013 03/22/2013
03/25/2013 04/19/2013
04/22/2013 05/17/2013
05/20/2013 06/14/2013

(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 _____

Supplemental Form
For International Medical School Students

Page 1

Please print or type:

Name:

Last

First

Middle

Have you spoken with or corresponded with a faculty member at Yale?

Yes

No

Yes

No

If yes, with whom?

Have you completed all basic science courses?

Yes

Have you completed a course of clerkship in:

No

Number
of
Patients

1) Physical Diagnosis
(physical examination and history taking)
2) Inpatient Internal Medicine
3) Outpatient Internal Medicine
4) Neurology
5) Obstetrics & Gynecology
6) Pediatrics
7) Psychiatry
Yes

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?

English Language Skills:

Knowledge of English:

Excellent

Written
Spoken

Good

No

Supplemental Form
For International Medical School Students

Page 2

Knowledge of Medical English:

Yes

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

No
Score

Have you taken the TOEFL? (required when English is not the primary language)
Have you taken Step 1 United States Medical Licensing Exam?

Please submit a personal statement describing your career goals, how this experience willhelp you achieve them, and what
you have accomplished thus far in pursuit of those goals. Also include what cultural opportunities you will pursue during
your stay. Please submit this statement in a separate document that is double-spaced and no more than one page
(approximately 250 words).

Your Signature

Official Signature
Dean of Your Medical School

Please Print or Type Deans Name

Certification (Seal)

Date