Application for Elective in Tropical Medicine

Complete in English only. Please print or type

Section I (To be completed by everyone. Please do not leave any entry blank. If it is not applicable to you type N/A)

Name:

Sex:

Nationality:

Complete Mailing Address:

Telephone Number:

Fax Number:

E Mail:

Date of Birth:

Emergency contact Name:

Phone number:

Medical School and address:

Expected Degree and Date (or degree and date of graduation for medical graduates):

What month would you prefer to do your elective ( A multidisciplinary structured elective is available only in July August and September for the year 1998- Please indicate first and second choices):

If you cannot take the regular course what month of the year would you like to take the clinical elective (July- September is not available; Indicate first and second choices)? :

Are you planning to take another elective in SRMC simultaneously? If yes what? (Other electives must be scheduled independently with the dean’s office):

Are you planning to stay on in a clinical elective? If yes how many more weeks?:

If you are a medical graduate would you like to take the shortened course or the regular course? :

Do you require in-campus housing?: If yes what are your preferences (Please circle one)
a) Single room with shared bath b) single room with bath c) family suite 

Section II: Health and immunization (To be completed by everyone)

TB skin test (PPD) status (please indicate dates) (if positive chest x-ray report required):

Immunization status (Indicate dates):

Tetanus /diphteria (Primary series + Td booster within the last 10 years)

MMR (or positive serology):

Hepatitis B (Series of three doses):

Have you had chicken pox? (if no please obtain a varicella antibody titer. If you are titer negative please take the chicken pox vaccine – 2 doses 4 –8 weeks apart):

Signature of the student:

Section III To be completed by the Registrar or dean’s office of Student’s medical School (Medical graduates proceed to section IV)

Please fill in the appropriate responses

Standard length of time to complete program years

Student’s year of medical school:

Is the student is approved to do electives away from home school:

Is the student in good standing:

Is the student fluent in English?:

Is a written evaluation required (if yes please enclose appropriate evaluation forms):

Authorized by:

Title

Please sign date and provide appropriate seal

Section IV For Medical Graduates only

Are you fluent in English? :

What is your specialty? :

Are you enrolled in a formal postgraduate training program? If yes give details:

Will this elective count towards credits in your training program (If yes please attach a letter of verification and approval from your program director):

MEDLINK is Ramachandra's own journal soon to be published both in print and simultaneously in the web. Watch this space!!!