ALPERT MEDICAL SCHOOL OF BROWN UNIVERSITY VISITING INTERNATIONAL MEDICAL STUDENT PROGRAM. Mailing Address: Country of Citizenship

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1 ALPERT MEDICAL SCHOOL OF BROWN UNIVERSITY VISITING INTERNATIONAL MEDICAL STUDENT PROGRAM Clinical Elective Application PLEASE PRINT CLEARLY First Name: Mailing Address: Middle Name: Last Name: Today s Date: Address Home Medical School: Year of Graduation from Medical School: Gender: Telephone Number: Date of Birth (month, day, year) Country of Citizenship Be advised that visiting international medical students may not ask for letters of recommendation from Brown faculty or hospital administrators, and cannot ask hospital staff or faculty to change electives. Not adhering to these policies will be cause for dismissal from an elective. STATEMENT OF DEAN FROM HOME MEDICAL SCHOOL (CIRCLE APPROPRIATE PHRASES) The medical student named above is in good standing at this institution, is in the FINAL year of a year program, and has approval to take the elective. Student [will] [will not] pay tuition at our school during the period indicated. Malpractice insurance [does] [does not] cover the student away from our school while taking approved work. Student [is] [is not] covered by student health insurance. Student [has] [has not] attended an educational session on the prevention of bloodborne and airborne pathogen infection in compliance with OSHA regulations. Student [has] [has not] attended an educational training session on HIPAA. At the conclusion of the course/clerkship an evaluation report [is] [is not] required. [Dean of home medical school must submit a letter attesting to the student's use of written and verbal English and affirming that the student s language skills are sufficient to communicate with patients, medical faculty, and others.] Printed Name: Signature: Title: Date: (School Seal) Only original signature and seal accepted.

2 STATEMENT OF VISITING INTERNATIONAL MEDICAL STUDENT I am aware that acceptance as a Visiting International Medical Student carries no implication concerning formal admission to or matriculation at Alpert Medical School. Evaluation of my performance while studying at Alpert Medical School is based on the same criteria as those used to evaluate matriculated medical students at Brown. As such, only the Alpert Medical School Clinical Evaluation Form will be provided at the end of the approved elective period. A completed Proof of Immunization form is attached to this application. I understand that I am required to pay a nonrefundable application fee of $ for EACH four-week period requested, upon submission of my completed application packet. I understand that I am also required to pay a tuition fee of $4,000 per 4-week elective to be completed between 5/1/2015 4/30/2016 upon submission of my completed application packet. No electives will be assigned until the tuition fee is paid and the application has been deemed complete. Do not send cash or personal checks. We are not responsible for any fees sent in cash. Cashier checks must be paid in U.S. dollars drawn on a U.S. bank. Applications sent with checks not drawn on U.S. banks will be considered incomplete and returned. American Express money orders may be used for payment in U.S. dollars. Checks or money orders must be payable to Brown University. The application fee must be paid separately from the clerkship tuition. Do not combine your payments for the application fee and tuition in the same check or money order. The tuition fee may be wired. Contact VIMS@Brown.edu for instructions. The application fee may NOT be wire transferred. Any application fees that are wire transferred will be returned to you and could result in your not being scheduled. Please contact us immediately if you wish to cancel your elective. If you notify us AT LEAST THREE MONTHS BEFORE the start of the rotation, your tuition payment will be refunded. No refund will be given if notification is received less than THREE MONTHS before the start of an elective, or if you withdraw after the elective has begun. I also understand that acceptance for an elective is made on a first-come, first-served basis. Priority in scheduling electives is given to Brown students and in rare situations, my assigned elective may be changed up until two weeks prior to the start date. In this eventuality, every effort will be made to provide me with another elective of my choice. I will be notified of the change and no refund will be given in this circumstance. By signing this form, I certify that as a visiting international medical student I understand that I may not ask for letters of recommendation from Brown faculty or hospital administrators, and after I am scheduled I will not ask hospital staff or faculty to change my elective. Not adhering to these policies will be cause for dismissal from an elective. Printed Name: Signature: Date: Address:

3 Students must adhere to Brown s elective calendar of dates. No exceptions will be made. DO NOT CONTACT THE HOSPITALS DIRECTLY. Please note that due to an increase in the size of classes at Alpert Medical School and the number of visiting medical students, elective choices may be very limited. Please provide plenty of choices. Be aware that Brown students have priority in scheduling and, in rare instances this could result in a visiting student being moved from their previously scheduled elective. We will make every effort to reassign the visiting student to another elective of his/her choice. I am interested in participating in total elective(s) and the following list is my choice of electives in order of preference (choose from the ELECTIVE LIST putting your top choice first on the list): Elective Number Elective Title Elective Dates

4 ALL APPLICATIONS MUST BE COMPLETE OR WILL BE RETURNED. DUE TO SHEAR VOLUME OF APPLICATIONS, WE CANNOT HOLD APPLICATIONS FOR SUPPLEMENTAL OR MISSING MATERIALS. Please check off and return the following: (1) Completed application form (2) Completed Statement of Dean with seal (3) Dean s letter attesting to your comprehension of spoken English and fluency of English speech (4) List of clerkships you have completed (5) Completed immunization form (6) Application fee(s) (7) Tuition fee (s) (8) Proof of health insurance (9) Proof of malpractice insurance from MMJUA (No alternate insurance will be accepted) (10) Proof of HIPAA Training (11) Proof of OSHA-Bloodborne Pathogen Training (12) Two (2) faculty letters of recommendation (13) Transcripts (14) Two (2) mini photos (15) Copy of your passport information page (16) TOEFL scores Mail the packet to: Warren Alpert Medical School of Brown University Clerkship Office 222 Richmond Street Box G-M118D Providence, RI 02912

5 Detailed list of all full-time hands-on clerkship experiences you will have completed before participating in clerkships at Alpert Medical School Title of Clerkship Specialty (eg Medicine, Pediatrics, etc.) Duration (in weeks) Was this a handson, full time experience? If not, explain. Student Name: Date:

6 PROOF OF IMMUNIZATION FORM VISITING INTERNATIONAL MEDICAL STUDENTS Name of Student: Visiting from (name of medical school): INFLUENZA: I will provide proof that I have been vaccinated against influenza within 12 months of arrival at Brown. Tdap: I will provide proof that I have been vaccinated with Tdap (Tetanus, Diphtheria, Pertussis) within the last 10 years. HEPATITIS B: I will provide proof of THREE doses of Hepatitis B vaccine (month/day/year) or serologic evidence of Hepatitis B immunity. MMR (Measles, Mumps, Rubella): I will provide proof (month/day/year) that I have been vaccinated with TWO doses of live virus MMR vaccine administered at least 28 days apart after my first birthday or individual vaccines as listed below: o MEASLES: I will provide proof (month/day/year) that I have been vaccinated with TWO doses of live virus measles (rubeola) vaccine administered at least 28 days apart after my first birthday or positive immunity titers. o MUMPS: I will provide proof (month/day/year) that I have been vaccinated with TWO doses of live virus mumps vaccine administered at least 28 days apart after my first birthday or positive immunity titers. o RUBELLA: I will provide proof (month/day/year) that I have been vaccinated with TWO doses of rubella vaccine administered at least 28 days apart after my first birthday or positive immunity titers. VARICELLA: I will provide proof (month/day/year) that I have been vaccinated with TWO doses of varicella vaccine administered 4 8 weeks apart or serologic evidence of varicella immunity. TB SCREENING (PPD): I will provide proof of TWO Tuberculosis Skin Tests (PPD) at least 2 weeks apart or one Quantiferon blood test, done within 6 months of arrival at Brown. If I have a positive result to either test, I will provide documentation of a negative chest x-ray and prophylaxis therapy. MENINGOCOCCAL vaccine (required if under 22 years old): I will provide proof that I have been vaccinated with Meningococcal; if the first dose was given before I was 16 years old I will provide the date of a booster dose. Immunization Documentation To be completed by student health service representative Month/Day/Year Month/Day/Year Month/Day/Year Influenza within 12 months of arrival at Brown Tdap (within last 10 years) Hepatitis B (three doses) Measles/Mumps/Rubella (two doses) Measles (two doses) Mumps (two doses) Rubella (two doses) PPD (*two skins tests at least 2 Placement date 1: Read date 1: Results (in mm) weeks apart, within 6 months of arrival at Brown) Placement date 2: Read date 2: Results (in mm) or one Quantiferon blood test Quantiferon test date: Varicella (shots or titer) Meningococcal (if under 22 years old) Dose 1: Booster: Student Health Service Representative s Signature, type name and title. Date: Any deviation from fulfilling all of the above health requirements will cause your application package to be returned to you and delay processing.

7 Online HIPAA Training Instructions Brown University is a member of the Collaborative Institutional Training Initiative (CITI), which is hosted by the University of Miami. To complete your HIPAA training, you will complete two brief online training modules, as well as the quiz at the end of each module. The entire process can be completed in less than one hour. Important note: when you have completed the modules and quizzes, be sure to print your Completion Report and be sure to include it with your application packet. Step 1: Go to To Access the Online HIPAA Training modules Click on the New Users Register Here link in the middle of the page (see below) Step 2: Register to use the site: A. Under Select your institution, click the pulldown menu to the right of the box under Participating Institutions and choose Brown University B. Follow the instructions to create a Username and Password Username must be between 4 and 50 characters and is not case sensitive. Your username can include letters, numbers, a period, an underline or symbol. Password must be between 8 12 characters, also not case sensitive, and can only include letters and numbers C. Enter your first and last name D. Enter your address. You are given the option of entering 2 addresses. E. Click Submit at bottom of page

8 Step 3: Answer Required Questions On the next page, answer the questions marked with an asterisk: Language Preference Institutional address (just fill in your Brown address) Gender Highest Degree Department (use Alpert Med School Exchange Student) Role in Research (use Student Researcher Graduate Level) Office Phone: (use ) May we contact you to complete a course survey (yes or no) Click Submit at bottom of page Step 4: CITI Course Enrollment Procedure A. Scroll to the bottom and click the link Continue to Question 1 at this time B. The next page is titled CITI Course Enrollment Questions Under #1 Human Subjects Research, click in the box next to the words Group 4: HIPAA training for Alpert Medical Students C. Click Submit at bottom of page D. The next page says Select Your Institution or Organization. Since you already selected Brown University at the beginning of the registration process, click NO at the bottom of the page Step 5: Taking the Training Modules A. From the Main Menu page, click the word Enter in the middle of the page, as shown below:

9 B. On the next page, click The Integrity Assurance Statement link, as shown below: C. Read the text on that page and select the appropriate statement at the bottom of the page and click the Submit button D. Click the link under Required Modules that is labeled HIPAA and Human Subjects Research. This brings you to the first training module, which takes minutes to complete. Step 6: Taking the Quiz A. Once you ve read the text, take the quiz, which consists of 2 questions, by clicking the link at the bottom of the page (see below) B. Generate the quiz by clicking the appropriate link (see below) C. Once you have answered the two questions for this module, click the Submit button and you will see your results.

10 D. At this point, you can: Go to the next training module, Privacy Rules: Students and Instructors Go to gradebook Go to the Main Menu and log out View the HIPAA training module again Submit a comment about the module Step7: After Completing both Training Modules and Quizzes A. Go to the Main Menu B. Print your Completion Report and save for your records (sample below). C. Save the Completion Report as one of the following formats: 1. PDF: right-click while the completion report is open and choose Convert to PDF 2. Word doc: copy the document and paste it into Word 3. Go to the File menu and choose Save As and select Text File (.txt) as the type. D. Name the saved file HIPAA training, followed by your last name. Example: HIPAA training.palenchar E. Please place a copy of the below certificate in your application packet: That s it you re done! Thanks for completing your HIPAA training course

11 OSHA Training If you have not had OSHA training, please use the following link: Proof of Malpractice Insurance Proof of coverage must be in English. Coverage must extend for your entire stay at Brown. The Warren Alpert Medical School does not provide malpractice insurance for Visiting International Medical Students during their Brown clinical elective. A local company that provides malpractice coverage to international students is Medical Malpractice Joint Underwriters Association at , or you mail Kizzy Moraldo at KMoraldo@beechercarlson.com. **Coverage provided by the Medical Defense Union is unacceptable. ** ***Brown cannot accept certificates from MPS (Royal College of Surgeons, Ireland) which will not provide adequate documentation of coverage. Please obtain your malpractice insurance from MMJUA RI.***

12 MEDICAL MALPRACTICE JOINT UNDERWRITING ASSOCIATION OF RHODE ISLAND One Turks Head Place, Suite 200 Providence, RI TEL.: (401) FAX: (401) Please complete application to obtain Professional Liability coverage through the MMJUA-RI. Name: (Last/ First) Policy Address: c/o The Warren Alpert Medical School of Brown University Box GM - 265, Providence, RI Fax #: Telephone #: Name & Address of Professional School Attended: Year of Graduation: Date of Birth: Coverage Period From: _To: _(12:01 a.m.) (Occurrence Coverage) Did you have any previous M.M.J.U.A.-R.I. Policies? Yes No Limits of Liability: x $1,000,000 each medical incident/$3,000,000 aggregate Specialty: x Medical Student - Coverage Code: Issue Certificate of Insurance to: The Warren Alpert Medical School of Brown University Box GM Providence, RI I hereby warrant that the information contained in this application is accurate and complete to the best of my knowledge. I understand that this application shall be considered a part of the terms and conditions of my insurance policy with the Joint Underwriting Association. (Signature of Applicant) (Date of Signature) (Applicant Address) PLEASE MAIL FORM TO MMJUA AT THE ADDRESS LISTED ABOVE. DO NOT SEND THIS PAGE TO BROWN WITH YOUR APPLICATION.

13 Health Insurance Information U.S. Department of State regulations require all J-1 Exchange Visitors and their accompanying J-2 dependents to have health insurance throughout the period of participation in the Exchange Visitor Program. Minimum acceptable coverage would provide: -medical benefits of at least $50,000 per accident or illness -repatriation of remains in the amount of $7,500 -expenses associated with medical evacuation in the amount of $10,000 -deductible not to exceed $500 per accident or illness Insurance coverage backed by the full faith and credit of the exchange visitor's home government also meets this requirement. Brown University has made arrangements to offer a policy that exceeds these minimum requirements through HTH Worldwide. The link for the HTH plan is: If you choose to buy your own health insurance coverage from another source, the insurance corporation underwriting the policy must have one of the following ratings: -an A.M Best rating of "A-" or above -an Insurance Solvency International, Ltd. (ISI) rating of "A-i" or above -a Standard & Poor's Claims paying Ability rating of "A-" or above -a Weiss Research, Inc. rating of "B+" or above

14 PRINCIPLES OF THE BROWN UNIVERSITY COMMUNITY We, as members of the Brown University community faculty, undergraduates, graduate and medical students, and staff are dedicated to supporting and maintaining a scholarly community in which all share together in the common enterprise of learning. As a central aim, Brown University promotes intellectual inquiry through vigorous discourse, both oral and written. The fundamental principles that must necessarily undergird this aim include respect for the integrity of the academic process; individual integrity and self-respect; respect for the freedoms and privileges of others; and respect for University resources. In becoming a part of Brown University, we accept the rights and responsibilities of membership in the University's academic and social community, and assume the responsibility to uphold the University's principles. RESPECT FOR THE INTEGRITY OF THE ACADEMIC PROCESS The rights and responsibilities that accompany academic freedom are at the heart of the intellectual purposes of the University. Our conduct as community members should protect and promote the University's pursuit of its academic mission. We are all, therefore, expected to conduct ourselves with integrity in our learning, teaching and research, and in the ways in which we support those endeavors. INDIVIDUAL INTEGRITY In order to ensure that the University can dedicate itself fully to its academic and educational vision, it is expected that an individual's personal integrity will be reflected not only in honest and responsible actions but also in a willingness to offer direction to others whose actions may be harmful to themselves or the community. The University expects that members of the Brown community will be truthful and forthright. The University expects that community members will not engage in behavior that endangers their own sustained effectiveness or that has serious ramifications for their own safety, welfare, academic well-being or professional obligations, or for that of others. RESPECT FOR THE FREEDOMS AND PRIVILEGES OF OTHERS We strive for a sense of community in which the individual growth of all members is advanced through the cultivation of mutual respect, tolerance, and understanding. Brown University values and encourages individuality while also affirming the community dimensions of academic life. A socially responsible community provides a structure within which individual freedoms may flourish without threatening the privileges or freedoms of other individuals or groups. The University is committed to honest, open, and equitable engagement with racial, religious, gender, ethnic, sexual orientation and other differences. The University seeks to promote an environment that in its diversity is integral to the academic, educational and community purposes of the institution. RESPECT FOR UNIVERSITY RESOURCES All community members must respect the general resources and physical property of the University. Such resources are assets in which community members have a vested interest, as these resources specifically support the institutional mission. STANDARDS OF CONDUCT The principles stated above are values that hold for the entire University community. Specific standards of conduct and procedures for redress of violation of those standards for each segment of the community can be found in the following University documents:

15 The University subscribes to an academic code. All students are expected to have read the academic code booklet, to be familiar with its principles, and to sign a statement acknowledging their responsibility for the code The standards and procedures for all students may be found in Brown University Student Rights and Responsibilities, published by the Office of Student Life. Medical students should look also to the Guiding Principles of Professional Behavior, set forth by the Brown Medical School, for additional information For specific information on rights and responsibilities, faculty should consult the Handbook of Academic Administration, which puts into practice the principles outlined in the document Faculty Rules and Regulations. Policies and procedures guiding staff conduct may be found in the Brown University Human Resources Policy & Procedure Manual, provided by the Human Resources department. GUIDING PRINCIPLES OF PROFESSIONAL BEHAVIOR THE WARREN ALPERT MEDICAL SCHOOL 'The mission statement of The Warren Alpert Medical School exhorts the members of the medical school community to view medicine "as a noble profession rather than a trade to be learned." We seek to graduate physicians who are socially responsible and committed to improving health care in their community, the nation and the world. To these ends, we strive to create and sustain a learning environment that nurtures the full development of our professional values. The Guiding Principles of Professional Behavior is informed by the altruistic tradition of medicine and proclaims our aspirations regarding what it means to be a professional in the context of our academic and clinical environments. Patient Advocacy. Patient care comes first. Socially responsible physicians undertake to improve the health of their patients, families and communities through their devotion to medicine and their advocacy for better health for all. Students and faculty participate in community outreach and advocacy and cultivate respect for cultural diversity. Faculty serves as role models and mentors for students, residents and fellows in striving to improve health care in the community, and to ensure that all patients regardless of their socioeconomic position receive quality health care. Respect for Others. Professionalism requires recognition of and respect for other persons. In the clinical setting, we are respectful and responsive to patients, their families, peers and the health care staff. In the academic context, faculty and administrators demonstrate respect by teaching or communicating in a thoughtful and sensitive manner. Students, residents and fellows reciprocate by participating constructively in teaching sessions and by providing and responding to appropriate feedback to and from faculty and administrators. Ethical Practice. In maintaining the public trust, all members of the medical school community strive to sustain the highest standards of academic and personal honesty, compassion, integrity, altruism, and dependability. The medical school promotes moral development by acting ethically and by setting and maintaining the highest ethical standards for faculty, staff and students. We take responsibility not only for our own behavior but that of our professional colleagues. In daily conduct with patients and with each other, we are fair and truthful. We act in a compassionate manner. In our professional communications, we report accurately and objectively, particularly when documenting patient care and in conducting research. When appropriate, we provide complete disclosure of self-interest and avoid and appropriately manage conflicts of interest. Self-Care and Self-Awareness. Recognizing that devotion to the profession can only be sustained in a life that is meaningful and balanced, the medical school expects its members to attend to their own health, emotional and social needs and well-being. Reflective professionals are aware of their obligation to themselves, their family, their community and patients to maintain good health. They are thoughtful about what in their lives has personal meaning including their professional and personal values, priorities and commitments. Autonomy and Academic Freedom. The medical school respects the autonomy of patients, students, residents and fellows. In caring for patients, we honor and uphold the principles of informed consent and shared decision-making. We understand and respect the professional boundaries of the physician/patient and the teacher/student

16 relationships. Our trainees are encouraged to shape their own learning to develop leadership skills and to pursue career and outside interests. As a community, we support the responsible exercise of freedom of speech and academic freedom. Such free and open communication may be required to advocate effectively for patient care. Lifelong Learning. As members of the The Warren Alpert Medical School community we have a continuing commitment to excellence in clinical practice and in scholarship. We are committed to lifelong learning through participation in continuing education, and to facilitating ongoing opportunities for students, residents, fellows and faculty to participate in professional development that enhances innovation and creativity in their teaching and scholarship. STUDENTS WITH DISABILITIES Brown University has as its primary aim the education of a highly qualified and diverse student body. The University offers equal educational opportunities and reasonable accommodations for the needs of qualified students with disabilities. Section 504 of the Federal Rehabilitation Act of 1973, reinforced by the Americans with Disabilities Act (ADA) of 1990, maintains that no qualified individuals with disabilities shall, solely on the basis of their disability, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity in higher education. Enclosed for your review are Brown's policies regarding the technical standards for medicine and the procedures for their evaluation. If you have a disability that you believe may affect your ability to meet the technical standards, please contact Linda_Conte@Brown.edu at (401) , as soon as possible to discuss your situation. If you do not contact Linda Conte, we understand you to be stating that you will be able to meet the competency requirements for medicine without any accommodations. TECHNICAL STANDARDS FOR MEDICINE Students applying to the Visiting International Medical Student program (VIMS) at Brown University must be capable of meeting the competency requirements expected of Brown medical students, with reasonable accommodation. The process for assessing whether applicants will be able to meet the competency requirements for the medical degree (MD), with reasonable accommodation, is described below. Process for Assessing Whether Applicants Meet Technical Standards for Medicine 1. Applicants with disabilities will be requested to have submitted on their behalf appropriate documentation in regard to the disability from a qualified health professional. The health professional will be asked to provide an opinion on the candidate's ability to meet the competency requirements. The applicant may also be requested to respond to that question. 2. The responses will be submitted to the Associate Dean of Medicine (VIMS) who will ascertain what accommodations, if any, the medical program would need to make in order that the applicant might be able to meet the competency requirements. I have read the Principles of the Brown University Community, the Guiding Principles of Professional Behavior of The Warren Alpert Medical School, and Students With Disabilities, and pledge to adhere to them. Signature Date Printed Name