3. Curriculum Vitae: Must be updated and uploaded (PDF format).
4. Official Medical School Transcript: Must include pre‐clinical and clinical courses. Grade(s) for the
Pediatrics Core rotation must be included on the transcript. (If any requirements are missing from
transcript your application is considered incomplete for review)
5. Letter of Recommendation: You will need 3 Letters. Must be submitted from a clinical preceptor and
included in PDF application packet (preferred) or directly to UTSW to the listed email below:
[email protected] (Attn: Anthony Lee – UTSW Sr. Education Coordinator)
All LORs must be submitted before your application is considered complete for review – Be
proactive in making sure your LORs are completed and submitted along with application.
6. USMLE Step 1: COMLEX Level 1 will be accepted in place of the USMLE Step 1 for DO students (A step 1 is
highly preferred). A copy of the score report is not required if the score is included in your school
transcript. There are no waivers granted.
7. Letter of Good Standing: An Attestation letter of good standing is required from your home institution
and must be included in the PDF application packet.
8. VISA: Current copy of your VISA must be included in your application packet. You be applying for an F‐1
VISA to rotate here at UTSW. No other VISAs are allowed. (No waivers are given)
9. Digital Photo Headshot: Please submit in .jpg format must be included in PDF application packet.
10. Medical Student Access Form: All rotation‐specific information can be left blank. I will fill in that
information if an elective is offered and accepted. Signature cannot be electronic.
The listed items below are UTSW requirements for all visiting student and must be completed after
being accepted to an elective before any rotation is approved by UTSW. All documents and instructions
are listed on the general UTSW Visiting Student Website.
International Student Application Checklist 2018‐19
Immunization Form
Background Check
Medical Liability
TB Mask Fit Test
Essential Functions Form
Universal Precautions Attestation
HIPAA Training
BLS/ACLS Certification
Drug Testing
Personal Health Insurance
REMINDER: All forms and documents must be completed and provided in PDF format to the specified
email above. Any missing documents will make your application incomplete and will not be reviewed.
STUDENT HEALTH SERVICES
IMMUNIZATION REQUIREMENTS
TETANUS One dose of tetanus/diphtheria/acellular pertussis (Tdap). Td/DPT/DtaP does not satisfy this requirement.
MEASLES (Rubeola) If you were born on or after January 1, 1957: Documentation of 2 doses of measles vaccine administered since January 1, 1968 or documentation of 2 doses of MMR vaccine administered since January 1, 1968 or documentation of 1 dose of measles vaccine and 1 dose of MMR vaccine administered since January 1, 1968 OR a positive titer confirming immunity or evidence of prior infection.
MUMPS If you were born on or after January 1, 1957: Documentation of 1 dose of mumps vaccine or documentation of 1 dose of MMR vaccine OR a positive titer confirming immunity or evidence of prior infection.
RUBELLA (German measles) If you were born on or after January 1, 1957: Documentation of 1 dose of rubella vaccine or documentation of 1 dose of MMR vaccine OR a positive titer confirming immunity or evidence of prior infection.
HEPATITIS B Documentation of 3 doses of hepatitis B vaccine OR a positive (QUANTITATIVE) titer confirming immunity.
VARICELLA (Chickenpox) Documentation of 2 doses of varicella vaccine OR a positive titer confirming immunity. History of disease not accepted.
TUBERCULOSIS SCREENING Documentation of 1 negative PPD tuberculin skin test OR a Quantiferon/T-Spot blood test within 6 months prior to starting your UTSW program. The blood test must be accompanied by the lab report.
POSITIVE TUBERCULIN SKIN TEST (PPD)/ TUBERCULOSIS SCREENING If you tested positive, or have a history of a positive PPD,
include the month, day, and year of the positive test on the form, and documentation of a chest x-ray within 6 months of starting your UTSW program. Chest x-ray results must include a copy of the radiology report.
MENINGITIS One dose of meningitis vaccine if you will be younger than age 22 prior to the beginning of classes. The vaccine must be administered within 5 years and at least 10 days prior to enrollment. (Students over 22 years old upon enrollment are not required to have meningitis immunization).
All immunizations must be documented and submitted along with your immunization form.
STUDENT HEALTH SERVICES
DOCUMENTATION REQUIREMENTS
All immunization requirements must be met prior to registration. Immunizations may be obtained from your current university student health services, private physician’s office, city/county health department or other clinics.
Acceptable documentation of immunizations includes one of the following: 1. Immunization form filled out and signed by your health care provider.2. Documentation of vaccines administered that includes the signature or stamp of the
physician or his/her designee, or public health personnel.3. An official immunization record generated from a state or local health authority, such as a
registry.4. A record received from school officials.
Please note: 1. Vaccines administered after September 1, 1991, shall include the month, day and year each
vaccine was administered. 2. Enclose a copy of the laboratory report on all immune titers (blood test). (For medical
students, many residency programs require immune titers for measles, mumps, rubella, varicella and hepatitis B. If you have insurance which will cover the cost of immune titers, you are encouraged to obtain the titers now.)
Please call 214-645-8690 if you have any questions regarding the required immunizations.
Mail all immunization information to: University of Texas Southwestern Medical Center
Student Health Services 5323 Harry Hines Blvd.
Dallas, Texas 75390-8861 Telephone (214) 645-8690
5323 Harry Hines Blvd. /Dallas, Texas 75390-8861 / (214) 645-8690
Essential Functions Required of StudentsEntering The University of Texas Southwestern Medical School
All individuals, including persons with disabilities, who apply for admission to UT Southwestern Medical School must be able to perform specific essential functions. Essential functions are the basic activities that a student must be able to perform to complete the generalist medical school curriculum. No applicant who can perform the medical school’s essential functions–either with or without reasonable accommodations–will be denied consideration for admission. A candidate for the M.D. degree must be able to perform these essential functions:
1. Observation: Candidates must be able to accurately observe demonstrations and patients close up and ata distance to learn skills and to gather patient data (e.g., observe a patient’s gait, appearance, posture,etc.). Candidates must also possess functional use of the sense of vision and somatic sensation.Observation is enhanced by the functional use of the sense of smell.
2. Communication: Candidates must be able to communicate orally and in writing with patients andmembers of the health-care team. Candidates also must be able to read and comprehend writtenmaterial.
3. Psychomotor Skills: Candidates must have sufficient motor function to obtain data from patients usingtactile, auditory, and visual maneuvers. Candidates must be able to execute motor movements toprovide general care and emergency treatment that are reasonably required of physicians.
4. Intellectual and Cognitive Abilities: Candidates must be able to measure, calculate, reason, analyze,synthesize, integrate, and apply information. Problem solving, a clinical skill required of physicians,requires all these intellectual abilities. In addition candidates must be able to comprehend 3-Drelationships and to understand the spatial relationships of structures.
5. Behavioral and Social Attributes: Candidates must possess the emotional health required to use theirintellectual abilities fully, such as exercising good judgment, promptly completing all responsibilitiesattendant to the diagnosis and care of patients, and developing mature, sensitive and effectiverelationships with patients. Candidates must be able to tolerate physically taxing workloads and tofunction effectively under stress. They must be able to adapt to changing environments, to displayflexibility, and to learn to function in the face of uncertainties and ambiguities inherent in the clinicalproblems of many patients. Compassion, integrity, concern for others, interpersonal skills, interest andmotivation are personal qualities that will be assessed during the admissions and education process.
6. Ethical Standards: A candidate must demonstrate professional demeanor and behavior, and mustperform in an ethical manner in all dealings with peers, faculty, staff, and patients. Candidates musttreat all patients equally without regard to ethnicity, race, gender, religion or any other attribute.
Please check below and sign: ( ) I can perform the specified essential functions.
( ) I cannot perform the essential functions without accommodations due to a disability. I understand that I must contact the Office of the Registrar (214-648-3606) to discuss any accommodations prior to being approved as a visiting student.
Last Name ____________ First Name ____________ Middle Name ____________ Preferred Name ____________
Gender: Male Female Date of Birth ________ Preferred Email _____________________________________
Address: Street _______________________________________________________________ Apt ______________
City _______________________ State ____________ Zip Code __________
Cell Phone _____________________ Home Phone _____________________ 4SSN/Passport # _________________
Medical School/Program ______________________________________________ UTSW ID # _________________
1st Year 2nd Year 3rd Year 4th Year 5th Year 6th Year N/A (International Students Only)
Rotation at Children’s Medical Center
Select One: Clerkship Elective Observation Research
Observation and Research complete the information below
Department _____________________ Coordinator _________________________ Phone Number _____________
Sponsoring Physician ________________________ Rotation Start Date ____________ End Date ______________
HIPAA Training: Where _________________________ Date _________________ (Month and Year)
Acknowledgement
I understand that my access at Children’s Medical Center (Children’s) for the duration of my medical school training and/or elective/observer rotation is dependent on accesses granted to me through Children’s GME credentialing and privileging process and that my badge is to be worn appropriately and visible at all times. I agree and understand that my ID / Password(s) are confidential and will not be shared and I will adhere to Children’s Security policies regarding use of these systems (Human Resources Policy 9.01 and Administrative Policy 9.16). I also understand that my access to Children’s will be terminated upon my completion of my medical school training and/or elective/observer rotation and if I was issued a Children’s badge I must return this badge to the Children’s Badge Office upon my completion of my ENTIRE medical school training and/or elective/observer rotation at Children’s.
_____________________________________________ ____________________ Signature Date
Universal Precautions should be followed by ALL personnel at ALL times on ALL patients. The use of Universal Precautions is based on an individual’s skills and interaction with a patient’s body substances, non-intact skin, and mucous membrane. This applies regardless of the patient’s diagnosis.
Compliance with universal precautions includes performance of all invasive procedures with the following actions undertaken:
1. All patients must be regarded as potentially infected with blood-borne pathogens.
2. Strict hand washing must be practiced before and after each patient contact. HANDS MUST BEWASHED IMMEDIATELY IF THEY ARE CONTAMINATED WITH BLOOD OR BODY FLUIDS.
3. Gloves must be worn:a. if soiling with blood or body fluids is anticipatedb. for placement of intravenous lines
Gloves should not be reused.
4. Gowns should be worn during procedures that are likely to generate splashes of blood or otherbody fluids and if soiling with blood or body fluids is likely.
5. Masks and protective eyewear (goggles) should be worn during procedures that are likely togenerate droplets or splashes of blood or other body fluids, to prevent exposure of mucousmembranes of the mouth, nose and eyes.
6. Disposable articles contaminated with blood or body fluids should be discarded in red bagslabeled “infectious waste”.
7. Non-disposable articles contaminated with blood or body fluids should be cleaned with anapproved disinfectant and autoclaved to sterilize.
8. Blood spills should be cleaned up promptly with a 1:10 bleach-water solution.
9. All specimens must be contained in a leak-proof plastic bag labeled “bio-hazard” for transport.
10. Care will be taken to avoid needle stick injuries. Used needles will not be recapped or bent; theywill be placed in an appropriately labeled puncture-resistant needle box.
I have read and received a copy of “Compliance with Universal Precautions” Education presentation and agree to follow the guidelines.
Signature ______________________________________________ Date ___________________________
FAQs
1. Can application requirements be waived?
No, all requirements are mandatory and will not be waived under any circumstances.
2. What is the elective fee?
Each elective is $25.00, which will be paid prior to your first day of registration via
online.
3. What is the $150.00 fee and when do I pay this fee?
The $150.00 fee is for International application processing and must be paid prior to any
review of your application by the pediatrics department. This is also paid via online.
4. Can an international student apply for a June/August rotation?
Yes, however the probability of you getting selected for this rotation is highly dependent
on your VISA processing, you must already have UTSW F‐1 VISA sponsorship in place.
5. Can I rotate at UTSW/Children’s without an F‐1 VISA?
No, all rotating international students must apply and get a UTSW F‐1 sponsored VISA
for EACH rotation.
6. Will my application be forwarded for review if I am missing any required documents?
No, only complete applications will be forwarded for review and consideration for an
elective slot.
7. Can I apply without my pediatrics core course grade included on my transcript?
No, you will be expected to have your pediatric grade by the time your application is
submitted. No exceptions are made.
8. When I submit the AAMC Immunization can the physician only sign the form?
No, you will need your home school to review and sign this form including the physician
that completed the immunization review.
9. Is a housing scholarship available for international students?
Yes, there is a housing scholarship, however it is a highly competitive scholarship and
based on your complete application. (only 2 students are awarded this scholarship per
academic year)
10. Can I do multiple elective rotations?
Yes, but each rotation will be processed individually and a separate UTSW F‐1 VISA
application must be submitted each time. Probability of getting multiple rotations is
highly unlikely as electives fill immediately and processing will not allow quick
turnaround.
11. Must I have personal health insurance if I am an international medical student?
Yes, you are required to show proof of personal insurance prior to your rotation and
during your rotation here at UTSW.
12. What type of background check must I complete?
You will need to complete a full background check including “International Criminal
Check” your application packet instructions will detail which site to use and other
pertinent codes to use when beginning the process.
Visiting Medical Student Registration Form (VMSRF) for UT Southwestern Electives
TO BE COMPLETED BY INTERNATIONAL OR NON-LCME VISITING STUDENT:
Gender:
US citizen?
Do you hold permanent residence status for the US?
Name (Last, First, Middle):
Local Address:
City: State: ZIP Code:
Female
Male
Birth Date:
Email Address:
Home Phone:
Home Medical School:
Emergency Contact: Phone #:
Yes No (if No, provide applicable information below.)
Yes No
Date permanent resident card issued:
What visa type do you hold?
Number:
Number:
Requested DateExample:
Course Number Requested Elective
1.
2.
Cell Phone (REQUIRED):
School Type:Non-LCMEInternational
Country:
Page 1 of 2
Last Revised 6/18/2014W:\Registrars Office\Med Forms\VMS Registration Form REVISED 6-18-14.pdf
***VISITING STUDENTS MAY ONLY COMPLETE TWO ROTATIONS AT UT SOUTHWESTERN.*** STEPS FOR APPLYING FROM INTERNATIONAL OR NON-LCME ACCREDITED MEDICAL SCHOOLS
Application must be completed and forwarded with supporting documents to the department coordinator of your chosen elective(s). The department coordinator will process all forms with the appropriate UT Southwestern administrative offices on the visiting medical student's behalf. Failure to complete Steps 1-2-3 will jeopardize any opportunity to pursue the elective as a visiting medical student.
Step 1 - Complete the Visiting Medical Student Registration Form (VMSRF). Step 2 - Individual academic departments may require a supplemental application with department specific instructions and requirements.
SEE SUPPLEMENTAL REQUIREMENTS ON VISITING STUDENT WEBPAGE Step 3 - Forward VMSRF with ALL required and supplemental documents to the UT Southwestern department coordinator for the rotation
you have chosen. SEE REQUIREMENTS ON VISITING STUDENT WEBPAGE for a list of suplemental documents and contact information of the Departmental Visiting Student Coordinators. REQUIRED DOCUMENTS:
* Application * Curriculum Vitae * Essential Functions Form * Immunization Record * Official Medical School Transcript * Photo * Department's Supplemental Applicaton/Documents (if applicable)
A complete packet of information MUST be sent to EACH department that you are applying to. Completed packets will receive priority in the review process.
Driver's License or Passport Number (REQUIRED):
Printed Name and Title of Authorized Official DateSignature of Authorized Official from UT Southwestern Department
TO BE COMPLETED BY UT SOUTHWESTERN DEPARTMENT:
Page 2 of 2
11. This student will be in his/her senior year at the time of the elective.
13. This student has met all immunization requirements or student health requirements as defined by our school.
14. This student has complied with HIPAA training requirements.
15. This student has completed a criminal background check at our institution.
10. This student will have successfully completed these core clerkships by the dates listed below:
Weeks
16. This student has passed USMLE Step 1.
Printed Name and Title of Authorized Official DateSignature of Authorized Official from Visiting Student's Home Institution
9. We require our student to hold personal health insurance.
TO BE COMPLETED BY VISITING STUDENT'S HOME INSTITUTION Yes No
1. This student is in good standing at this institution and has my approval for the elective listed above.
2. This student has been instructed in OSHA safety measures and infection control precautions.
3. This student has a current ACLS.
4. This student has a current BLS.
5. This student has completed a Mask Fit Test.
6. This student is taking electives for credit.
7. This student will pay tuition at the home school during the period indicated.
8. Medical liability and/or malpractice insurance will be covered by the home school during this elective time.
Comment
Date expires:
Date expires:
Date expires:
Aggregate Insurance:
Per Instance Insurance:
Online Policy URL:
Policy Expiration Date:
MM/YYYY
MM/YYYY
MM/YYYY
MM/YYYY
Internal Medicine
ClerkshipDate Completed MM/DD/YYYY
Surgery
Pediatrics
Obstetrics and Gynecology
Weeks
Psychiatry
ClerkshipDate Completed MM/DD/YYYY
Family Medicine
Neurology
12. This student is expected to graduate in:
Health Requirements URL:
Date expires:
2.
1. ApprovedDenied
DeniedApproved
MM/DD/YYYY
MM/DD/YYYY
17.This student has completed drug testing at our institution.Date expires: MM/DD/YYYY
MMR (Measles, Mumps, Rubella) – 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1) dose of Rubella; or serologic proof of immunity for Measles, Mumps and/or Rubella
Hepatitis B Vaccination --3 doses of vaccine followed by a QUANTITATIVE Hepatitis B Surface Antibody (titer) preferably drawn 4-8 weeks after 3rd dose. If negative, complete a second Hepatitis B series followed by a repeat titer. If Hepatitis B Surface Antibody is negative after a secondary series, additional testing including Hepatitis B Surface Antigen should be performed. See: http://www.cdc.gov/mmwr/pdf/rr/rr6103.pdf for more information. Documentation of Chronic Active Hepatitis B is for rotation assignments and counseling purposes only.
Primary Hepatitis B Series
Date
Hepatitis B Vaccine Dose #1 ___/___/_____
Hepatitis B Vaccine Dose #2 ___/___/_____
Hepatitis B Vaccine Dose #3 ___/___/_____
QUANTITATIVE Hep B Surface Antibody ___/___/_____
Result _______ mIU/ml
Copy Attached
Secondary Hepatitis B Series
(If no response to primary series)
Hepatitis B Vaccine Dose #4 ___/___/_____
Hepatitis B Vaccine Dose #5 ___/___/_____
Hepatitis B Vaccine Dose #6 ___/___/_____
QUANTITATIVE Hep B Surface Antibody ___/___/_____
Result _______ mIU/ml
Copy Attached
Hepatitis B Vaccine Non-responder
(If Hepatitis B Surface Antibody Negative after Primary and Secondary
TUBERCULOSIS SCREENING – Results of last (2) TSTs (PPDs) or (1) IGRA blood test are required regardless of prior BCG status. If you have a history of a positive TST (PPD)>10mm or IGRA please supply information regarding any evaluation and/or treatment below. You only need to complete ONE section.
Skin test or IGRA results should not expire during proposed elective rotation dates or
must be updated with the receiving institution prior to rotation.
Tuberculin Screening History
Ple
ase
com
ple
te o
ne
TB
sec
tio
n o
nly
Section A Date Placed Date Read Reading Interpretation
Negative Skin or Blood Test
History
Last two skin test
or IGRAs required
Use additional rows as needed
TST #1 ___/___/____ ___/___/____ ____ mm Pos Neg Equiv
Influenza Vaccine --1 dose annually each fall Flu Vaccine ___/___/____ Copy Attached
Flu Vaccine ___/___/____ Copy Attached
Additional Information:
MUST BE COMPLETED BY YOUR HEALTH CARE PROVIDER OR INSTITUTIONAL REPRESENTATIVE:
Authorized Signature: Date: ___/___/____
Printed Name:
Office Use Only Title:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone: (____) ______-____________ Ext: _______
Fax: (____) ______-____________
Email Contact:
*Sources: 1. Hepatitis B In: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine‐Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds.
13th ed. Washington D.C. Public Health Foundation, 2015 2. Immunization of Health‐Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR, Vol 60(7):1‐45 3. Updated CDC Recommendations for the Management of Hepatitis B Virus–Infected Health‐Care Providers and Students, MMWR Vol 61(RR03):1‐12.
