MSU-CHM/GRMEP Application for Elective Clerkship Section I
To be completed by student
Name
Medical School
(First
MI
Last)
Address
School Address
Phone
School Contact Person
Email
School Contact Phone
*NOTE: Must be a professional (university/institution) address,
personal email (gmail, yahoo, etc.) not accepted.
School Contact E-mail
Date of Birth
Emergency Contact Name/Phone Number
Gender
 Male
 Female
Last 4 Digits of SSN
If this application is for a Michigan State University College of Osteopathic Medicine student, check
appropriate box:
 Selective  Elective
Selective/Elective Date Requests (all date requests must start and end on a weekday)
1st Choice
Dates:
to
2nd Choice
Dates:
to
3rd Choice
Dates:
to
Are you considering applying to one of our residencies?
 Yes
If yes, which residency program are you interested in?
Administrator | VISITING MEDICAL STUDENT | 12/15
 No
 Unsure
MSU-CHM/GRMEP Application for Elective Clerkship Section II
To be completed by student and verified by medical school
Prior to the requested elective clerkship(s), I will have completed the following 3rd year required clerkships:
 Family Medicine
 Internal Medicine
 Pediatrics
% Outpt
% Inpt
______
______
______
______
______
______
 Surgery
 OB/Gyn
 Psychiatry
% Outpt
% Inpt
______
______
______
______
______
______
Have you passed USMLE Step 1 OR COMLEX Level 1 Exam?
 Yes
Score
Number of times taken_____________



 No
Have you passed USMLE Step 2 Clinical Knowledge OR COMLEX Level 2 Exam?
Score
Number of times taken
 Yes  No
Have you passed USMLE Step 2 Clinical Skills Exam OR COMLEX Clinical Skills Exam?
Number of times taken___
____
Are you currently authorized to be in and study in the United States?
 Yes  No
 Yes  No
If not a U.S. citizen or permanent resident, what is the visa status that permits you to live and study in the United
States?
(attach copy of visa to application)
Have you completed the following required Joint Commission/HIPAA educational requirements?
 Yes  No  Unknown
Completed required HIPAA General Orientation
Date last completed
Have you completed the following required training within the 12 months preceding the requested elective(s)?
 Yes  No  Unknown
Universal Precautions
Date late completed
 Yes  No  Unknown
Blood Borne Pathogens
Date last completed
MSU-CHM/GRMEP Application for Elective Clerkship Section III
To be completed by medical school Dean of Student Affairs or designee
Please provide the following information on:
(Please print student name)
 Yes  No
The above named student is a student in good standing.
Expected Date of Graduation:
 Yes  No
S/he is approved to take the requested elective(s).
Administrator | VISITING MEDICAL STUDENT | 12/15
 Yes
 No
S/he will be covered by home medical school liability insurance while rotating at MSU/CHM.
Please state per instance amount / aggregate insurance amount:
 Yes
 No
S/he will be paying tuition and receiving credit for this elective at home medical school.
Our records show that this student has:
 Yes
 No
 Unknown
Personal health coverage which will be in effect during this elective.
 Yes
 No
 Unknown
This student has acute or chronic health problems or special accommodations
that need to be in place to successfully complete this elective.
If yes, explain
Immunizations:
 Yes  No  Unknown
***Documentation of health information listed below must be attached***
Provides documentation of negative PPD. If has had a reactive PPD in the past
and a negative chest X-ray, must provide documentation of a negative symptom
review.
 Yes
 No
 Unknown
Received a Tetanus/Diphtheria vaccination within the last 10 years.
Date of last Tetanus/Diphtheria vaccination:
 Yes
 No
 Unknown
Received an adult Pertussis vaccination.
 Yes
 No
 Unknown
Proof of seasonal influenza vaccine (required between 10/1 and 3/31)
 Yes
 No
 Unknown
Received 3 doses of Polio vaccine.
 OPV
OR
 IPV
 Yes
 No
Meets Rubeola Requirement:
(1) If student was born before 1957:
 One dose of live Rubeola vaccine or proof of immunity
(serology or physician-documented history of disease)
OR
(2) If student was born after 1957:
 Two doses of live Rubeola vaccine on or after the 1st birthday and spaced at
least 28 days apart or proof of immunity
(serology or physician-documented history of disease)
 Yes
 No
Meets Rubella Requirement:
One does of live Rubella vaccine on or after the 1st birthday
OR proof of immunity (serology)
 Yes
 No
Meets Mumps Requirement:
(1) If student was born before 1957:
 One dose of live Mumps vaccine or proof of immunity
(serology or physician-documented history of disease)
Administrator | VISITING MEDICAL STUDENT | 12/15
OR
(2) If student was born after 1957:
 Two doses of live Mumps vaccine on or after the 1st birthday and spaced at
least 28 days apart or proof of immunity
(serology or physician-documented history of disease)
 Yes
 No
Meets Varicella Requirement:
Two doses of Varicella vaccine (at least 4 weeks apart)
OR evidence of immunity (serology or physician/parent-documented history of
disease)
 Yes
 No
Meets Hepatitis B Vaccine:
Three doses of Hepatitis B vaccine
Vaccination Dates:
Meets Hepatitis B Proof of Immunity:
A positive titer is required, unless it has been over one year since your
third dose.
(Must attach copy of serology report showing immunity)
Date of titer:
If the titer is negative, additional vaccinations required:
Vaccination Dates:
I authorize my Dean’s office, Institutional Compliance Officer or physician to provide all verification and health
information in Sections II and III of this application.
Student Signature
Date
AFFIX SCHOOL
SEAL
I verify that all information in Sections II and III of this application are accurate.
Signature
Printed Name, Dean of Student Affairs
(or designee)
Date
RETURN COMPLETED APPLICATION AND SUPPORTING DOCUMENTS TO:
Sidra Tees, GME Scheduling Assistant
Grand Rapids Medical Education Partners
Michigan State University College of Human Medicine, Grand Rapids Campus
945 Ottawa Ave NW
Grand Rapids, MI 49503
[email protected]
Phone: 616.732.6235
Fax: 616.233.6635
ELECTIVE WILL NOT BE PROCESSED UNTIL REQUIRED PAPERWORK IS RECEIVED
Administrator | VISITING MEDICAL STUDENT | 12/15
Section IV: To be completed by the Visiting Student
Last Name
First Name
Middle Initial
Email address
*NOTE: Must be a professional (university/institution) address, personal email (gmail, yahoo, etc.) not accepted.
Contact Phone Number
School
Graduation Date
ROTATION REQUEST(s)
Dates
1st Choice
TO
2nd Choice
TO
3rd Choice
TO
Office Use Only
Approved
Date Coming
Type of Learner
Application Processed
Administrator | VISITING MEDICAL STUDENT | 12/15
BACKGROUND INVESTIGATION RELEASE STATEMENT
Print Full Name
Other Names Used
Date of Birth *
Social Security Number
Drivers License Number
State/Country
Home Address History:
Current home address first – Include city, county, state, zip, country, and dates at each address
(Must have at least prior 10 years of home address):
Address, City, County, State, Zip, Country
1.
2.
3.
4.
5.
Administrator | VISITING MEDICAL STUDENT | 12/15
Dates at address
(List current address first)
Name:
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Administrator | VISITING MEDICAL STUDENT | 12/15
Name:
Employment History/Information
1. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Dates of employment
2. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Dates of employment
3. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Dates of employment
4. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Dates of employment
5. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Administrator | VISITING MEDICAL STUDENT | 12/15
Dates of employment
Name:
6. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Dates of employment
7. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Dates of employment
8. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Dates of employment
9. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Dates of employment
10. Name of employer
Name of supervisor
Address, city, state, zip, country
Area code-Phone number
Administrator | VISITING MEDICAL STUDENT | 12/15
Dates of employment
Name:
*Date of Birth to be used exclusively for record checking purposes and will not be used for any other
purposes.
Prior to your Visiting Learner Rotation and as part of the Visiting Learner Application process with Grand
Rapids Medical Education Partners, I understand that investigative background inquiries are going to be made
on me. I understand that you will be requesting information from various Federal, State, Local and other
agencies which maintain records concerning my past activities relating to my driving history, credit, criminal,
civil and other experiences. These reports may also include inquiries regarding my educational history and
past work experience and performance including reasons for termination of employment.
I authorize, without reservation, any party or agency contacted by this employer or its agents to furnish any of
the above mentioned information or any other information requested. I understand that such information
may contain my social security number. I release all parties from all liability for any damage that may result
from furnishing that information to this company.
I understand that the information generated, received or maintained during and as a result of this
investigation will be maintained as confidential information.
A photocopy of this document is considered to be as valid as the original document.
I acknowledge that I have received a copy of my rights under the Fair Credit Reporting Act.
Signature:
Must be hand signed. Typed electronic signatures cannot be accepted.
Date:
Email Address:
Phone Number:
Administrator | VISITING MEDICAL STUDENT | 12/15
Visiting Learner Non-Refundable
Application Fee
$250.00
***Application fee subject to change***
Med Student VL 5180-199
Learner Name:
Requested Rotation:
Dates of Rotation:
Credit Card Number:
CVV / Security Number:
Credit Card Expiration:
Learner Signature:
Mail to:
Sidra Tees
GME Scheduling Department
Grand Rapids Medical Education Partners
945 Ottawa Ave NW
Grand Rapids, MI 49503
Fax to:
616.233.6635
Confidentially email to:
[email protected]
**NOTE: Credit cards (Visa, MC), money orders, or cashier’s checks will be accepted.
**No Discover or AMEX cards, personal checks, or cash.
Administrator | VISITING MEDICAL STUDENT | 12/15
Visiting Medical Student Checklist
 I understand each program has different application requirements and limitations and submission of an application
does not constitute approval of rotation request or that I will be granted my top choice elective.
 I understand that acceptance for an elective rotation does not guarantee a residency interview in that specialty. Time
away from a rotation to interview outside the Grand Rapids area is generally prohibited.
 I understand visiting medical students are limited to one four-week rotation in their fourth/final year only and must
have successfully completed the basic required clerkship in the discipline of the requested rotation.
 The Dean of Student Affairs or designee has verified the information in Sections I and II of my application and has
completed and signed Section III. I understand my application will not be reviewed unless it is complete.
 I understand if I am accepted for a rotation, I will be contacted and asked to complete a mandatory drug screen.
 I have attached (or requested from my school) copies of all required documentation, including but not limited to:
 Certificate of Professional Liability Insurance which will provide coverage while rotating with Grand Rapids
Medical Education Partners (GRMEP/MSU does not provide liability coverage for visiting students)
 Student must carry minimum $1 million occurrence and $3 million aggregate liability insurance
 Documentation confirming my immunization history including but not limited to Whooping Cough (DPT or
TDaP), MMR, Rubella, Rubeola, Varicella, Hepatitis B, Flu, and TB
 I hereby release Spectrum Health Occupational Medicine, Grand Rapids Medical Education Partners and
Mercy Health Saint Mary’s Employee Health Office and its employees, staff and agents from all legal
responsibility or liability that may arise from the disclosure of the information set forth relating to my file.
 I have completed the background investigation release statement (above) and understand my rights under the Fair
Credit Reporting Act.
 I have attached the credit card form (below) for my $250 non-refundable application fee
(application fee only charged if student is accepted/confirmed for a rotation)
 If accepted for a rotation at GRMEP/MSU, the student agrees to the following:
 Student will arrange his/her own housing and transportation.
 Student will complete any required institutional and rotation-specific orientations.
 Student will wear GRMEP and hospital issued ID badge(s); short, white lab coat; and adhere to rotation-specific
dress code at all times.
 Student will comply with all GRMEP and specific training site policies.
 Student will perform assigned duties to the best of his/her ability and work assigned shifts.
 Student will maintain patient confidentiality by following all HIPAA regulations.
 Student will provide his/her preceptor with his/her school’s evaluation form and instructions on returning it.
 Any rotation changes or cancellations should be communicated to Sidra Tees at GRMEP as soon as possible and
within 60 days of the rotation start date. Students should not contact preceptors independently.
 Submit completed application via mail to: Sidra Tees, 945 Ottawa Ave NW, Grand Rapids, MI 49503. Email to
[email protected] or fax to 616-233-6635.
Applicant’s Signature
Printed Name
Administrator | VISITING MEDICAL STUDENT | 12/15
Date