JUNTENDO UNIVERSITY FACULTY OF MEDICINE

CLINICAL OBSERVERSHIP PROGRAM APPLICATION

Personal Information Experience Application Information Immunization Requirements

Given Names

Surname
For visa purposes enter your name as listed on your passport.

Name in ひらがな
If you have a preference for how your name is written in Japanese please enter it above.

Date of Birth

Nationality

Address

Email

Telephone Number

Native Language

TOEFL

IELTS

JLPT

Other Language Tests

Japanese Listening Speaking Reading Speaking

English Listening Speaking Reading Speaking

for STUDENTS:

Name of University

Country of University

University URL

Academic Year Year of Year Program

Enter academic year at the time of the program at Juntendo University.

for DOCTORS:

Employer

Country of Employer

Employer URL
 Position

Contact Person
Juntendo University will contact this person in the case of an emergency.
The contact person needs to be from your university.

Title

Position

Department

Email

Address

Telephone

URL

Recommender
Enter the information of the person who wrote the letter of recommendation.

Title

Position

Department

Email

Address

Telephone

URL

Funding
Select the option that best describes your primary source of funding for your stay in Japan.

Additional Details

If the selections above do not describe how you will fund your stay, provide additional details.

Government Employment
Are you employed by a non-Japanese government agency in any capacity?

Government Funding
Are you receiving funding from a non-Japanese government agency in any capacity?
Personal Information Experience Application Information Immunization Requirements

Academic History
- Enter academic history following graduation from high school. Do not include high school information.

- Enter expected date of graduation if currently enrolled in an academic program.

- List your three most recent academic degrees below. If you have additional degrees, list them in the Experience tab of this file.

Name of School Country Degree Major Start Finish

Employment History
- List your two most recent employment experiences below. If you have additional experiences, list them in the Experience tab of this file.

Employer Country Position Speciality Start Finish

Clinical Experience
- List your two most recent clinical experiences below. If you have additional experiences, list them in the Experience tab of this file.

Healthcare Institution Country Position Department Start Finish

Awards
- List your two most recent awards below. If you have additional awards, list them in the Experience tab of this file.

Scholarship Name, Scholarship Foundation Year

Personal Information Experience Application Information Immunization Requirements

Describe your reason and purpose for applying to Juntendo University (limit 100 words):

Desired Departments Period

- Period should start on a Monday and finish on a Friday.

- Openings tab lists the department openings.

Department Start Finish

Department Statements
- Please see the "Example" tab to get a better understanding of what is needed for the department statements.

Department One:

Preparation before attending the department:

Motivation for applying to the department:

Cases would like to experience while in the department:

 Department Two:

Preparation before attending the department:

Motivation for applying to the department:

Cases would like to experience while in the department:

Department Three:

Preparation before attending the department:

Motivation for applying to the department:

Cases would like to experience while in the department:

How did you find out about the = Teacher = Other

program?
Select as many choices that apply. = Friend Please Specify

= Internet

Personal Information Experience Application Information Immunization Requirements

Immunization Requirements
If you already completed the immunization requirements, completing the following is not necessary.
List how you completed or plan to complete the immunization requirements.

Measles Measles
Completed, how did you complete the requirement? Incomplete, how will you complete the requirement?

= Received two vaccinations
= Titer report greater than 800 mIU/ml or 16.0 E
= Titer report between 100 - 799 mIU/ml or 2.0 - 15.9 EIA, will
receive one additional vaccination
= Titer report less than 100 mIU/ml or 2.0 EIA, will receive two
additional vaccinations
= Will submit a titer report and receive additional vaccination(s) if
nessecary.

Mumps
Completed, how did you complete the requirement?
= Received two vaccinations
= Titer report greater than 200 mIU/ml or 4.0 EI
Rubella
Completed, how did you complete the requirement?
= Received two vaccinations
= Titer report greater than 400 mIU/ml or 8.0 EI
Varicella
Completed, how did you complete the requirement?
= Received two vaccinations
= Titer report greater than 200 mIU/ml or 4.0 EI
Hepatitis B
Completed, how did you complete the requirement?
= Received three vaccinations and HBsAB titer
report greater than 10 mIU/ml
Will submit a titer report and receive additional vaccination(s) if
nessecary.
= Received one vaccination, will receive one additional vaccination
= Will receive two vaccinations or submit proof of two vaccination
= Date plan to submit requirement
Mumps
Incomplete, how will you complete the requirement?
= Titer report between 100 - 199 mIU/ml or 2.0 - 3.9 EIA, will
receive one additional vaccination
= Titer report less than 100 mIU/ml or 2.0 EIA, will receive two
additional vaccinations
= Will submit a titer report and receive additional vaccination(s) if
nessecary.
= Received one vaccination, will receive one additional vaccination
= Will receive two vaccinations or submit proof of two vaccination
= Date plan to submit requirement
Rubella
Incomplete, how will you complete the requirement?
= Titer report between 100 - 399 mIU/ml or 2.0 - 7.9 EIA, will
receive one additional vaccination
= Titer report less than 100 mIU/ml or 2.0 EIA, will receive two
additional vaccinations
= Will submit a titer report and receive additional vaccination(s) if
nessecary.
= Received one vaccination, will receive one additional vaccination
= Will receive two vaccinations or submit proof of two vaccination
= Date plan to submit requirement
Varicella
Incomplete, how will you complete the requirement?
= Titer report between 100 - 199 mIU/ml or 2.0 - 3.9 EIA, will
receive one additional vaccination
= Titer report less than 100 mIU/ml or 2.0 EIA, will receive two
additional vaccinations
= Will submit a titer report and receive additional vaccination(s) if
nessecary.
= Received one vaccination, will receive one additional vaccination
= Will receive two vaccinations or submit proof of two vaccination
= Date plan to submit requirement
Hepatitis B
Incomplete, how will you complete the requirement?
= Titer report below 10 mIU/ml, will receive an additional HB
vaccination and 30 days after the vaccination take an additional
HBsAb test
= Received three vaccinations and will submit HBsAB titer report,
if nessecary will receive an additional vaccination(s) and submit
an additional HBsAb titer report
 = Received three vaccinations and will submit HBsAB titer report,
if nessecary will receive an additional vaccination(s) and submit
an additional HBsAb titer report

= Will submit proof of three vaccinations and HBsAB titer report

greater than 10 mIU/ml

= Date plan to submit requirement

Tuberculosis Tuberculosis
Completed, how did you complete the requirement? Incomplete, how will you complete the requirement?

= PPD Skin Test: induration less than 10 mm * = Will take a PPD skin test, if nessecary will take an x-ray *

= IGRA Blood Test: negative * = Will take an IGRA blood test, if nessecary will take an x-ray *

= X-ray report indicating no signs of tuberculosis = Will take an x-ray *

* Report must be within one year of the = Date plan to submit requirement
program start date.

Influenza Influenza
Completed, how did you complete the requirement? Incomplete, how will you complete the requirement?

= Received vaccination = Will receive a vaccination

= Program between May 1 - September 30, not = Date plan to submit requirement
required

COVID-19 COVID-19
Completed, how did you complete the requirement? Incomplete, how will you complete the requirement?

= Received vaccination = Will receive vaccination(s)

= Date plan to submit requirement

Immunization Requirements Status Immunization Requirements Pledge

= Completed Only applicants whose Juntendo University Hospital Immunization

Requirements ("immunization requirements") status is incomplete, need to
read and acknolwedge the Immunization Requirement Pledge.
✔ = Incomplete

If accepted, I ( ) understand that in the case I do not complete all of

the immunization requirements, I will not be able to attend the
Juntendo University Clinical Observership Program ("program"), even
if Juntendo University issues a letter of acceptance.

If accepted, I understand that my immunization requirements must be

confirmed two weeks prior to the start of my program. If I do not
submit the immunization requirements two weeks prior to the start of
my program, my program may be delayed.

If my program is cancelled or I experience a delay to the start of my

program due to the immunization requirements, Juntendo University
will not be responsible for any expenses or burdens I may experience
as a result of not being able to attend the program.

= I have read and acknowledge the above Immunization

Requirement Pledge.
("program")
unization Requirements
unization Requirements

Finish

Finish

Finish

Year Month
unization Requirements

d finish on a Friday.

penings.
unization Requirements

or 2.0 - 15.9 EIA, will

0 EIA, will receive two

dditional vaccination(s) if
dditional vaccination(s) if

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or 2.0 - 3.9 EIA, will

0 EIA, will receive two

dditional vaccination(s) if

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or 2.0 - 7.9 EIA, will

0 EIA, will receive two

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or 2.0 - 3.9 EIA, will

0 EIA, will receive two

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nation take an additional
ubmit HBsAB titer report,
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ubmit HBsAB titer report,
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will take an x-ray *

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### ###
Personal Information Experience Application Information Immunization Requirements

Academic History
Name of School Country Degree Major Start Finish

Employment History

Employer Country Position Speciality Start Finish

Clinical Experience
Healthcare Institution Country Position Department Start Finish

-
 -

Awards
- List your two most recent awards below. If you have additional awards, list them in the Experience tab of this file.

Scholarship Name, Scholarship Foundation Year

 ###
unization Requirements

Finish

Finish

Finish
Year Month
KEY
Grey = No Openings Mo n d a y ,Ma y 2 0 ,2 0 2 4 T u e s d a y ,Ma y 2 1 ,2 0 2 4 We d n e s d a y ,Ma y 2 2 ,2 0 2 4 T h u rs d a y ,Ma y 2 3 ,2 0 2 4 F rid a y ,Ma y 2 4 ,2 0 2 4 Mo n d a y ,Ma y 2 7 ,2 0 2 4 T u e s d a y ,Ma y 2 8 ,2 0 2 4 We d n e s d a y ,Ma y 2 9 ,2 0 2 4 T h u rs d a y ,Ma y 3 0 ,2 0 2 4 F rid a y ,Ma y 3 1 ,2 0 2 4 Mo n d a y ,J u n e 3 ,2 0 2 4 T u e s d a y ,J u n e 4 ,2 0 2 4 We d n e s d a y ,J u n e 5 ,2 0 2 4 T h u rs d a y ,J u n e 6 ,2 0 2 4
Fri day, June 7, 2024 Mo n d a y ,J u n e 1 0 ,2 0 2 4 T u e s d a y ,J u n e 1 1 ,2 0 2 4 We d n e s d a y ,J u n e 1 2 ,2 0 2 4 T h u rs d a y ,J u n e 1 3 ,2 0 2 4 F rid a y ,J u n e 1 4 ,2 0 2 4 Mo n d a y ,J u n e 1 7 ,2 0 2 4 T u e s d a y ,J u n e 1 8 ,2 0 2 4 We d n e s d a y ,J u n e 1 9 ,2 0 2 4 T h u rs d a y ,J u n e 2 0 ,2 0 2 4 F rid a y ,J u n e 2 1 ,2 0 2 4 Mo n d a y ,J u n e 2 4 ,2 0 2 4 T u e s d a y ,J u n e 2 5 ,2 0 2 4 We d n e s d a y ,J u n e 2 6 ,2 0 2 4 T h u rs d a y ,J u n e 2 7 ,2 0 2 4 F rid a y ,J u n e 2 8 ,2 0 2 4 Mo n d a y ,J u ly 1 ,2 0 2 4 T u e s d a y ,J u ly 2 ,2 0 2 4 We d n e s d a y ,J u ly 3 ,2 0 2 4 T h u rs d a y ,J u ly 4 ,2 0 2 4
Fri day, Jul y 5, 2024 Mo n d a y ,J u ly 8 ,2 0 2 4 T u e s d a y ,J u ly 9 ,2 0 2 4 We d n e s d a y ,J u ly 1 0 ,2 0 2 4 T h u rs d a y ,J u ly 1 1 ,2 0 2 4 F rid a y ,J u ly 1 2 ,2 0 2 4 Mo n d a y ,J u ly 1 5 ,2 0 2 4 T u e s d a y ,J u ly 1 6 ,2 0 2 4 We d n e s d a y ,J u ly 1 7 ,2 0 2 4 T h u rs d a y ,J u ly 1 8 ,2 0 2 4 F rid a y ,J u ly 1 9 ,2 0 2 4 Mo n d a y ,J u ly 2 2 ,2 0 2 4 T u e s d a y ,J u ly 2 3 ,2 0 2 4 We d n e s d a y ,J u ly 2 4 ,2 0 2 4 T h u rs d a y ,J u ly 2 5 ,2 0 2 4 F rid a y ,J u ly 2 6 ,2 0 2 4 Mo n d a y ,J u ly 2 9 ,2 0 2 4 T u e s d a y ,J u ly 3 0 ,2 0 2 4 We d n e s d a y ,J u ly 3 1 ,2 0 2 4 T h u rs d a y ,A u g u s t1 ,2 0 2 4 F rid a y ,A u g u s t2 ,2 0 2 4 Mo n d a y ,A u g u s t5 ,2 0 2 4 T u e s d a y ,A u g u s t6 ,2 0 2 4 We d n e s d a y ,A u g u s t7 ,2 0 2 4 T h u rs d a y ,A u g u s t8 ,2 0 2 4 F rid a y ,A u g u s t9 ,2 0 2 4 Mo n d a y ,A u g u s t1 2 ,2 0 2 4 T u e s d a y ,A u g u s t1 3 ,2 0 2 4 We d n e s d a y ,A u g u s t1 4 ,2 0 2 4 T h u rs d a y ,A u g u s t1 5 ,2 0 2 4 F rid a y ,A u g u s t1 6 ,2 0 2 4 Mo n d a y ,A u g u s t1 9 ,2 0 2 4 T u e s d a y ,A u g u s t2 0 ,2 0 2 4 We d n e s d a y ,A u g u s t2 1 ,2 0 2 4 T h u rs d a y ,A u g u s t2 2 ,2 0 2 4 F rid a y ,A u g u s t2 3 ,2 0 2 4 Mo n d a y ,A u g u s t2 6 ,2 0 2 4 T u e s d a y ,A u g u s t2 7 ,2 0 2 4 We d n e s d a y ,A u g u s t2 8 ,2 0 2 4 T h u rs d a y ,A u g u s t2 9 ,2 0 2 4 F rid a y ,A u g u s t3 0 ,2 0 2 4 Mo n d a y ,S e p te mb e r2 ,2 0 2 4 T u e s d a y ,S e p te mb e r3 ,2 0 2 4 ### T h u rs d a y ,S e p te mb e r5 ,2 0 2 4 F rid a y ,S e p te mb e r6 ,2 0 2 4 Mo n d a y ,S e p te mb e r9 ,2 0 2 4 T u e s d a y ,S e p te mb e r1 0 ,2 0 2 4 ### T h u rs d a y ,S e p te mb e r1 2 ,2 0 2 4 F rid a y ,S e p te mb e r1 3 ,2 0 2 4 Mo n d a y ,S e p te mb e r1 6 ,2 0 2 4 T u e s d a y ,S e p te mb e r1 7 ,2 0 2 4 ### T h u rs d a y ,S e p te mb e r1 9 ,2 0 2 4 F rid a y ,S e p te mb e r2 0 ,2 0 2 4 Mo n d a y ,S e p te mb e r2 3 ,2 0 2 4 T u e s d a y ,S e p te mb e r2 4 ,2 0 2 4 ### T h u rs d a y ,S e p te mb e r2 6 ,2 0 2 4 F rid a y ,S e p te mb e r2 7 ,2 0 2 4 Mo n d a y ,S e p te mb e r3 0 ,2 0 2 4 T u e s d a y ,O c to b e r1 ,2 0 2 4 We d n e s d a y ,O c to b e r2 ,2 0 2 4 T h u rs d a y ,O c to b e r3 ,2 0 2 4 F rid a y ,O c to b e r4 ,2 0 2 4 Mo n d a y ,O c to b e r7 ,2 0 2 4 T u e s d a y ,O c to b e r8 ,2 0 2 4 We d n e s d a y ,O c to b e r9 ,2 0 2 4 T h u rs d a y ,O c to b e r1 0 ,2 0 2 4 F rid a y ,O c to b e r1 1 ,2 0 2 4 Mo n d a y ,O c to b e r1 4 ,2 0 2 4 T u e s d a y ,O c to b e r1 5 ,2 0 2 4 We d n e s d a y ,O c to b e r1 6 ,2 0 2 4 T h u rs d a y ,O c to b e r1 7 ,2 0 2 4 F rid a y ,O c to b e r1 8 ,2 0 2 4 Mo n d a y ,O c to b e r2 1 ,2 0 2 4 T u e s d a y ,O c to b e r2 2 ,2 0 2 4 We d n e s d a y ,O c to b e r2 3 ,2 0 2 4 T h u rs d a y ,O c to b e r2 4 ,2 0 2 4 F rid a y ,O c to b e r2 5 ,2 0 2 4 Mo n d a y ,O c to b e r2 8 ,2 0 2 4 T u e s d a y ,O c to b e r2 9 ,2 0 2 4 We d n e s d a y ,O c to b e r3 0 ,2 0 2 4 T h u rs d a y ,O c to b e r3 1 ,2 0 2 4 F rid a y ,N o v e mb e r1 ,2 0 2 4 Mo n d a y ,N o v e mb e r4 ,2 0 2 4 T u e s d a y ,N o v e mb e r5 ,2 0 2 4 ### T h u rs d a y ,N o v e mb e r7 ,2 0 2 4 F rid a y ,N o v e mb e r8 ,2 0 2 4 Mo n d a y ,N o v e mb e r1 1 ,2 0 2 4 T u e s d a y ,N o v e mb e r1 2 ,2 0 2 4 ### T h u rs d a y ,N o v e mb e r1 4 ,2 0 2 4 F rid a y ,N o v e mb e r1 5 ,2 0 2 4 Mo n d a y ,N o v e mb e r1 8 ,2 0 2 4 T u e s d a y ,N o v e mb e r1 9 ,2 0 2 4 ### T h u rs d a y ,N o v e mb e r2 1 ,2 0 2 4 F rid a y ,N o v e mb e r2 2 ,2 0 2 4 Mo n d a y ,N o v e mb e r2 5 ,2 0 2 4 ### ### ### F rid a y ,N o v e mb e r2 9 ,2 0 2 4

Red = No Openings 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24

Purple = No Openings 5 5 6 6 6 6 7 7 7 7 7 8 8 8 8 9 9 9 9 9 10 10 10 10 11 11 11 11

Blue = Openings 20 21 22 23 24 27 28 29 30 31 3 4 5 6 7 10 11 12 13 14 17 18 19 20 21 24 25 26 27 28 1 2 3 4 5 8 9 10 11 12 15 16 17 18 19 22 23 24 25 26 29 30 31 1 2 5 6 7 8 9 12 13 14 15 16 19 20 21 22 23 26 27 28 29 30 2 3 4 5 6 9 10 11 12 13 16 17 18 19 20 23 24 25 26 27 30 1 2 3 4 7 8 9 10 11 14 15 16 17 18 21 22 23 24 25 28 29 30 31 1 4 5 6 7 8 11 12 13 14 15 18 19 20 21 22 25 26 27 28 29

White = Openings (Exceptions may apply) M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F

Departments Maximum Maximum

Length of the Number Accepted 23 23 23 23 23 29 29 29 29 29 20 20 20 20 20 19 19 18 18 18 16 16 16 16 16 19 19 19 19 19 25 25 25 25 27 27 27 27 27 23 23 23 23 23 24 24 24 24 24 17 17 17 17 17 17 17 17 17 16 16 16 16 16 19 19 19 19 19 22 22 22 22 22 20 20 18 18 19 19 19 19 19 18 17 17 17 9 9 9 9 9 9 9 9 9 6 6 6 6 6 7 7 7 7 7 6 6 6 6 5 5 5 5 5 4 4 4 4 4 4 4 4 4 4
Program at One Time

Anesthesia and Pain Medicine 2-8 Weeks 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Cardiovascular Medicine 2 Weeks 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2
Cardiovascular Surgery 2 Weeks 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Clinical Laboratory Medicine 1 Week 1
Clinical Oncology 1 Week* 1 1 1 1 1 1
Coloproctological Surgery 8 Weeks 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Emergency and Disaster Medicine Main Hospital 2 Weeks 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Emergency and Disaster Medicine Urayasu Hospital 1 Week 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Emergency and Disaster Medicine Shizuoka Hospital 1 Week 3 2 2 2 2 2 1 1 1 1 1 1 1 1 1
Esophageal and Gastroenterological Surgery 2 Weeks 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 1 1 1 1
Gastroenterological Imaging and Interventional Oncology 1 Week 1
Gastroenterology 2 Weeks 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 2 2 2 2 2 2 1 1 1
General Medicine 2 Weeks 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
General Thoracic Surgery 1 Week 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Hematology 2 Weeks 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Hepatobiliary Pancreatic Surgery 8 Weeks 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Human Pathology 4 Weeks 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Nephrology 1 Week 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Neurology 2-8 Weeks 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1
Neurosurgery 5 Weeks 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Obstetrics and Gynecology 2 Weeks 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Ophthalmology 1 Week 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Otorhinolaryngology 2 Weeks 2 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Pediatric General and Urogenital Surgery 8 Weeks 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Pediatrics and Adolescent Medicine 2-4 Weeks 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Plastic and Reconstructive Surgery 8 Weeks 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 1 1 2 2 2 2 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
Psychiatry and Behavioral Science* 4 Weeks 1 1 1 1 1
Radiation Oncology 1 Week 1 1 1 1 1 1 1 1 1 1
Radiology General 1 Week 1
Radiology Neuro 8 Weeks 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 1 1 1 1
Rehabilitation Medicine 8 Weeks 2 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Rheumatology 1 Week 1 1 1 1 1 1 1 1 1 1 1
Urology 4 Weeks 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 1 1 1 1
.
This file is updated multiple times a week.
*Clinical Oncology is able to accept four observers in one year, around one observer every three months for one week.

*Psychiatry and Behavioral Science requires applicants pass the Japanese Language Proficiency Test (JLPT) N1 to apply
to the department.
The colors in this file may not appear properly if not opened in Excel. Below is a sample of how the colors should
appear. If the colors do not appear you can still determine if there are openings in most cases by looking at the
maximum number accepted at one time column and the number in the cell for each specific date.
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### JUNTENDO UNIVERSITY FACULTY OF MEDICINE
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CLINICAL OBSERVERSHIP PROGRAM APPLICATION
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Personal Information Experience Application Information Immunization Requirements

Given Names Elizabeth

Surname Turner
For visa purposes enter your name as listed on your passport.

Name in ひらがな エリザベス ターナー

If you have a preference for how your name is written in Japanese please enter it above.

Date of Birth 1998 5 15

Nationality Nationality

Address Number, Street, City, State, Zip Code, Country

Personal Email ElizabethTurner@gmail.com

University Email ElizabethTurner@university.edu

Telephone Number 81-(0)3-3813-3795

Native Language Language

TOEFL

IELTS 7.0

JLPT

Other Language Tests

Japanese 2 = Beginner 2 = Beginner 2 = Beginner 2 = Beginner

English 4 = Advanced 4 = Advanced 4 = Advanced 4 = Advanced

Name of University Juntendo University

Country of University Japan

University URL https://www.juntendo.ac.jp/english/

Academic Year 5th Year of 6 Year Program

Enter academic year at the time of the program at Juntendo University.

Contact Person Firstname Lastname

Juntendo University will contact this person in the case of an emergency.
The contact person needs to be from your university.

Title Ms.

Position Study Abroad Director

Department Study Abroad Office

 Department Study Abroad Office

Email studyabroad@juntendo.ac.jp

Address Number, Street, City, State, Zip Code, Country

Telephone 81-(0)3-3813-3795

URL https://en.juntendo.ac.jp/

Recommender Firstname Lastname

Enter the information of the person who wrote the letter of recommendation.

Title Dr.

Position Dean

Department School of Medicine

Email department@juntendo.ac.jp

Address Number, Street, City, State, Zip Code, Country

Telephone 81-(0)3-3813-3795

URL https://en.juntendo.ac.jp/

Funding Personal savings

Select the option that best describes your primary source of funding for your stay in Japan.

Government Employment No
Are you employed by a non-Japanese government agency in any capacity?

Government Funding No
Are you receiving funding from a non-Japanese government agency in any capacity?
### ###
Personal Information Experience Application Information Immunization Requirements

Academic History
- Enter academic history following graduation from high school. Do not include high school information.

- Enter expected date of graduation if currently enrolled in an academic program.

- List your three most recent academic degrees below. If you have additional degrees, list them in the Experience tab of this file.

Name of School Country Degree Major Start Finish

Juntendo University Japan MD Medicine 2017 4 - 2023

Employment History
- List your two most recent employment experiences below. If you have additional experiences, list them in the Experience tab of this file.

Employer Country Position Speciality Start Finish

Clinical Experience
- List your two most recent clinical experiences below. If you have additional experiences, list them in the Experience tab of this file.

Healthcare Institution Country Position Department Start Finish

Juntendo University Japan Student University Electives 2021 9 - 2022

Awards
- List your two most recent awards below. If you have additional awards, list them in the Experience tab of this file.

Scholarship Name, Scholarship Foundation Year

Juntendo University Study Abroad Scholarship, Juntendo University, Japan 2019
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Personal Information Experience Application Information Immunization Requirements

Describe your reason and purpose for applying to Juntendo University (limit 100 words):

As a medical student, while I have been exposed to great amounts of theory, I wish to explore the clinical aspects of medicine
to gain a better understanding of how my acquired knowledge can be applied to patients in a hospital setting. This program’s
exposure to medicine in practice would strengthen my knowledge, clinical skills, and qualities of care and compassion. Having
an interest in Japanese culture, I am excited to study at Juntendo University’s renowned medical faculty, and to observe the
latest breakthroughs with the phenomenal technology. This opportunity would definitely enrich my journey as a future medical
professional.

Desired Departments
- Period should start on a Monday and finish on a Friday.

Department Start Finish

Breast Oncology (Breast Surgery) 2022 11 7 - 2022 11 18

Obstetrics and Gynecology 2022 11 21 - 2022 12 2

Pediatrics and Adolescent Medicine 2022 12 5 - 2022 12 16

Department Statements
- Please see the "Example" tab to get a better understanding of what is needed for the department statements.

- Applicants who do not include the nessecary information will need to rewrite their statements.

Department One:

Preparation before attending the department:

During my surgical attachment I spent some time in the breast division, and saw a range of benign and malignant cases from presentation to
post-operative follow up.

Motivation for applying to the department:

I was fascinated by the psycho-social impact of breast surgery on patients, and surprised by the range of responses to surgery. I would like
to better understand the full process from initial presentation to recovery and discharge.

Cases would like to experience while in the department:

I would be particularly interested to see presentations of malignant disease, and the discussion of which type of surgery best fits the patient
and how to achieve this while managing their further needs.
 Department Two:

Preparation before attending the department:

I have recently completed an 8 week rotation in obstetrics and gynecology which helped develop a newfound passion for this medical
specialty.

Motivation for applying to the department:

I thoroughly enjoyed being part of a special process of bringing life into this world., and the experience of understanding the health
difficulties that women go through has been highly educational and invaluable. My rotation has trained me in appropriate management of
women and fetuses throughout pregnancy and birth, women`s health, and neonatology.

Cases would like to experience while in the department:

I hope to learn more about routine antenatal checks, miscarriage management, induction of labor methods, caesarian sections, and
postpartum issues such as hemorrhages and mental health.

Department Three:

Preparation before attending the department:

I completed a 6-week placement at university my university in pediatrics.

Motivation for applying to the department:

After the placement, I decided to become a paediatrician in my career. It is vitally important to me that we nurture the health and wellbeing
of future generations, and I'm fascinated by your research into preventing adult lifestyle related disease from childhood. The
biopyschosocial elements of childcare are critical to their mental development

Cases would like to experience while in the department:

I would love to observe the creative play therapy you're introducing and the "Mitsubachi" recovery room with a goal to encourage these
advances in the UK. I'm excited by the learning opportunities with neonates, nutrition, mental development and more.

How did you find out about the = Teacher = Other

program?
Select as many choices that apply. = Friend Please Specify

● = Internet

Additional Comments (optional):

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Personal Information Experience Application Information Immunization Requirements

Immunization Requirements
List how you completed or plan to complete the immunization requirements.

Measles Measles
Completed, how did you complete the requirement? Incomplete, how will you complete the requirement?
● = Received two vaccinations
= Titer report greater than 800 mIU/ml or 16.0 E
Mumps
Completed, how did you complete the requirement?
● = Received two vaccinations
= Titer report greater than 200 mIU/ml or 4.0 EI
Rubella
Completed, how did you complete the requirement?
● = Received two vaccinations
= Titer report greater than 400 mIU/ml or 8.0 EI
Varicella
Completed, how did you complete the requirement?
= Received two vaccinations
● = Titer report greater than 200 mIU/ml or 4.0 EI
= Titer report between 100 - 799 mIU/ml or 2.0 - 15.9 EIA, will
receive one additional vaccination
= Titer report less than 100 mIU/ml or 2.0 EIA, will receive two
additional vaccinations
= Will submit a titer report and receive additional vaccination(s) if
nessecary.
= Received one vaccination, will receive one additional vaccination
= Will receive two vaccinations or submit proof of two vaccination
= Date plan to submit requirement
Mumps
Incomplete, how will you complete the requirement?
= Titer report between 100 - 199 mIU/ml or 2.0 - 3.9 EIA, will
receive one additional vaccination
= Titer report less than 100 mIU/ml or 2.0 EIA, will receive two
additional vaccinations
= Will submit a titer report and receive additional vaccination(s) if
nessecary.
= Received one vaccination, will receive one additional vaccination
= Will receive two vaccinations or submit proof of two vaccination
= Date plan to submit requirement
Rubella
Incomplete, how will you complete the requirement?
= Titer report between 100 - 399 mIU/ml or 2.0 - 7.9 EIA, will
receive one additional vaccination
= Titer report less than 100 mIU/ml or 2.0 EIA, will receive two
additional vaccinations
= Will submit a titer report and receive additional vaccination(s) if
nessecary.
= Received one vaccination, will receive one additional vaccination
= Will receive two vaccinations or submit proof of two vaccination
= Date plan to submit requirement
Varicella
Incomplete, how will you complete the requirement?
= Titer report between 100 - 199 mIU/ml or 2.0 - 3.9 EIA, will
receive one additional vaccination
= Titer report less than 100 mIU/ml or 2.0 EIA, will receive two
additional vaccinations
= Will submit a titer report and receive additional vaccination(s) if
nessecary.
= Received one vaccination, will receive one additional vaccination
= Will receive two vaccinations or submit proof of two vaccination
= Date plan to submit requirement
Hepatitis B
Completed, how did you complete the requirement?
● = Received three vaccinations and HBsAB titer
report greater than 10 mIU/ml
Tuberculosis
Completed, how did you complete the requirement?
= PPD Skin Test: induration less than 10 mm *
= IGRA Blood Test: positive *
= X-ray report indicating no signs of tuberculosis
* Report must be within one year of the
program start date.
Influenza
Completed, how did you complete the requirement?
● = Received vaccination
= Program between May 1 - September 30, not
required
COVID-19
Completed, how did you complete the requirement?
● = Received vaccination
Immunization Requirements Status
= Completed
✔ = Incomplete
Hepatitis B
Incomplete, how will you complete the requirement?
= Titer report below 10 mIU/ml, will receive an additional HB
vaccination and 30 days after the vaccination take an additional
HBsAb test
= Received three vaccinations and will submit HBsAB titer report,
if nessecary will receive an additional vaccination(s) and submit
an additional HBsAb titer report
= Will submit proof of three vaccinations and HBsAB titer report
greater than 10 mIU/ml
= Date plan to submit requirement
Tuberculosis
Incomplete, how will you complete the requirement?
= Will take a PPD skin test, if nessecary will take an x-ray *
= Will take an IGRA blood test, if nessecary will take an x-ray *
● = Will take an x-ray *
2022 9 1 = Date plan to submit requirement
Influenza
Incomplete, how will you complete the requirement?
= Will receive a vaccination
= Date plan to submit requirement
COVID-19
Incomplete, how will you complete the requirement?
= Will receive vaccination(s)
= Date plan to submit requirement
Immunization Requirements Pledge
Only applicants whose Juntendo University Hospital Immunization
Requirements ("immunization requirements") status is incomplete, need to
read and acknolwedge the Immunization Requirement Pledge.
If accepted, I (Elizabeth Turner) understand that in the case I do not
complete all of the immunization requirements, I will not be able to
attend the Juntendo University Clinical Observership Program
("program"), even if Juntendo University issues a letter of acceptance.
If accepted, I understand that my immunization requirements must be
confirmed two weeks prior to the start of my program. If I do not
submit the immunization requirements two weeks prior to the start of
my program, my program may be delayed.
If my program is cancelled or I experience a delay to the start of my
program due to the immunization requirements, Juntendo University
will not be responsible for any expenses or burdens I may experience
as a result of not being able to attend the program.
 If my program is cancelled or I experience a delay to the start of my
program due to the immunization requirements, Juntendo University
will not be responsible for any expenses or burdens I may experience
as a result of not being able to attend the program.

● = I have read and acknowledge the above Immunization

Requirement Pledge.
("program")
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unization Requirements
 ###
unization Requirements

Finish

2023 3

Finish

Finish

2022 12

Year Month
2019 12
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unization Requirements

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y, and to observe the
urney as a future medical

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ropriate management of

arian sections, and

re the health and wellbeing

dhood. The

goal to encourage these

more.

###
unization Requirements
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t proof of two vaccination

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