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 HIPPA. 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 $3,800 per 4-week elective to be completed between 5/1/2013 4/30/2014 or $4,000 per 4-week elective to be completed between 5/1/2014 4/30/2015 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 the following 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-M265 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 hands-on, full time experience? If not, explain. Student Name: Date:

6 PROOF OF IMMUNIZATION 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 or serologic evidence of Hepatitis B immunity. MEASLES: I will provide proof 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. MUMPS: I will provide proof that I have been vaccinated with live virus mumps vaccine administered on or after my first birthday, or positive immunity titers. RUBELLA: I will provide proof that I have been vaccinated with rubella vaccine administered on or after my first birthday or positive immunity titers. VARICELLA: I will provide proof that I have been vaccinated with TWO doses of varicella vaccine administered 4 8 weeks apart or serologic evidence of varicella immunity. TB SCREENING: I will provide proof of TWO Tuberculosis Skin tests (PPD) at least 2 weeks apart, done within 6 months of arrival at Brown. If I have a non negative result to the test, I will provide documentation of a chest x ray and if indicated, prophylaxis therapy. Immunization Documentation To be completed by licensed Health Care Provider or Student Health Service Representative Month/Day/Year Month/Day/Year Month/Day/Year Influenza (shot) within 12 months of arrival at Brown Tdap Booster (within last 10 years) Hepatitis B THREE doses Measles/Mumps/Rubella - TWO doses Measles - single dose Mumps - single dose Rubella - single dose PPD (a) TWO skins tests (b) at least 2weeks apart (c) within 6 months of arrival at Brown) Placement date 1: Read date 1: Results (in mm) Placement date 2: Read date 2: Results (in mm) Varicella (shots or titer) TWO doses Health Care Provider s Signature, type name and title. Date:_

7 Proof of Health Insurance Proof of coverage must be in English. Coverage must extend for your entire stay at Brown. All Exchange Visitors are required to maintain health and accident insurance coverage during the entire time they participate in an Exchange Visitor program. The Exchange Visitor regulations specify a minimum level of coverage. Medical benefits of at least $50,000 per accident or illness Repatriation of remains in the amount of $7500 Expenses associated with medical evacuation of the Exchange Visitor to his or her home country in the amount of $10,000 A deductible not to exceed $500 per accident or illness. Any insurance policy secured to fulfill the above requirements, must be underwritten by an insurance corporation having an A.M. Best rating of "A" or above, an Insurance Solvency International, Ltd. (ISI) rating of "A-1" or above, a Standard and Poor's Claims-paying Ability rating of "A" or above, a Weiss Research, Inc. rating of "B+" or above, or such other rating service that the Exchange Visitor Program may specify. Insurance coverage backed by the full faith and credit of the government of the Exchange Visitor's home country shall be deemed to meet the requirement. An Exchange Visitor who willfully fails to maintain the insurance coverage as set forth or who makes a material misrepresentation to the sponsor regarding the coverage will be considered to be in violation of the USIA regulations and will be subject to termination as an Exchange Visitor participant. It is the exchange visitor s responsibility, not Brown's, to obtain and maintain insurance coverage. The following is a list of frequently used health insurance companies that meet the minimum requirement for students/ scholars. This list is not meant to endorse any one company over the other. International Student Organization A H Insurance Associated Insurance Plans 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.***

8 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) PLEASE MAIL FORM TO MMJUA AT THE ADDRESS LISTED ABOVE. DO NOT SEND THIS PAGE TO BROWN WITH YOUR APPLICATION.

9 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

10 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:

11 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.

12 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

13 OSHA Training If you have not had OSHA training, please use the following link: