UWHC Uniform Graduate Medical Education form
(for non-ERAS applicants)
This worksheet may be used to begin completing your application electronically. All required fields are marked with an asterisk (*). Please note, however, that some of these fields are required only in certain circumstances. For example, if you state that you did earn or expect to receive a degree from an institution, you will be required to enter what that degree is.
Profile
First Name:Middle Name: Last Name: Suffix:
Previous Last Name:
Degree: MD MD, PhD DO MBBS MBchS
Marital Status: Married Single Unknown
Current Address:
Street Address:
City:State/Province: Post Code: Country:
Preferred Phone: Alternate Phone: Mobile:
Pager: Fax: Contact Email:
Permanent Mailing Address:
Street Address:
City : State/Province: Post Code:
Country: Phone:
Gender: Female Male No Response
BirthBirth Date: BirthCity: BirthState: Birth Country
Social Security Number: SSN: Canadian SIN:
Military
Are you committed to fulfill U.S. Military active duty service obligations/deferments? *
Yes No
If Yes: Years: Branch:
Do you have any other service obligations? (i.e., Military Reserves or Public Health/State programs) *
Yes No
Description (up to 255 characters)
Racial and Ethnic Group:
This section allows entries for race self-identification. You may select one or more races. You are not required to identify your race. If you choose not to, please select "No Answer." Specify "other" if your race is not listed. You may create as many entries as needed.
No Answer
Black (not of Hispanic Origin): All persons having origins from any of the black racial groups.
Asian or Pacific Islanders: All persons having origins from any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, Samoa, and India.
American Indian or Alaskan Native: All persons having origins of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.
Hispanic: All persons from Mexican, Puerto Rican, Cuban, Central or South American, Iberian Peninsula, or other Spanish culture or Origin, regardless of race.
White (not of Hispanic Origin): All persons having origins from any of the original peoples of Europe, North Africa, and the Middle East.
Unknown
Other: ______
Citizenship Status: *
Current and Expected Visa Types: (for Foreign Nationals only - check all that apply)
B-1 - Temporary visitor for business
B-2 - Temporary visitor for pleasure
F-1 - Academic student business, or athletics
F-2 - Spouse or child of F-1
TN - NAFTA trade visa for Canadians and Mexicans
H-1 - Temporary worker
TN - NAFTA trade visa for Canadians and Mexicans
H-1B - Specialty occupation, DoD worker, etc.
Diplomatic Service
H-2B - Temporary worker- skilled and unskilled
Immigrant
H-4 - Spouse or child of H-1, H-2, H-3
EAD-Employment Authorization
J-1 - Visa for exchange visitor
J-2 - Spouse or child of J-1
O-1 - Extraordinary ability in sciences, arts, education,
Other
**UniversityHospital and Clinics only sponsors J1 training Visa’s for residents and fellows.
Expected Visa Type (for training)
J1
EAD
Other ______
Foreign Medical Graduates:
Are you certified by the Educational Commission for Foreign Medical Graduates?
(Attach a copy of the ECFMG certificate). Check all that apply.
No Yes Month: Year:
USMLE/ECFMG ID:
ECFMG certificate is attached with the application. *
Miscellaneous
Foreign Medical Graduates applying for Residency Positions: To be answered by Foreign Medical Graduates only. See for information and mailing instructions.
Will you provide a MSPE to the UWHC? * Yes No
Will you or your medical school provide a transcript to UWHC? * Yes No
**Please attach copies and a translation if not in English
Non-Medical Education
For each non-medical educational institution you have attended, please provide the requested information. You may create as many entries as needed on an additional page.
None
#1
Institution: Location:
Education Type: * Major: Degree expected or earned: * Yes No
Degree: Degree Month: Degree Year:
Dates of Attendance: From: To:
Month/year Month/year
#2
Institution: Location:
Education Type: * Major: Degree expected or earned: * Yes No
Degree: Degree Month: Degree Year:
Dates of Attendance: From: To:
Month/year Month/year
Refer to attachment for additional information. (Reference as 3-a, 3-b)
Medical Education
For each medical school you have attended, please provide the requested information. You may create as many entries as needed on an additional page.
#1
Country: Institution:
Clinical Campus: * only available for select US Medical Schools
Degree expected or earned: * Yes No
Degree: Degree Month: Degree Year:
Dates of Attendance: From: To:
Month/year Month/year
#2
Country: Institution:
Clinical Campus: * only available for select US Medical Schools
Degree expected or earned: * Yes No
Degree: Degree Month: Degree Year:
Dates of Attendance: From: To:
Month/year Month/year
#3
Country: Institution:
Clinical Campus: * only available for select US Medical Schools
Degree expected or earned: * Yes No
Degree: Degree Month: Degree Year:
Dates of Attendance: From:To:
Month/year Month/year
Refer to attachment for additional information. (Reference as 3-c)
Match Participation:
I am applying for position outside the match.
I am participating in the NRMP Main Match.
I am participating in the NRMP Specialties Match.
I am participating in a match as part of a couple AND I wish to notify programs of this.
San Francisco Matching Service
AUA Number: (required for Urology Match Participants only)
Other
Specialties Partner is applying to: Partner’s Name:
Cardiopulmonary Resuscitation & Other Life Saving Intervention Certification
I am CPR/BLS (Cardiopulmonary Resuscitation) certified in the U.S.A Expiration Date:
Month/year
I am ACLS (Advanced Cardiac Life Support) certified in the U.S.A. Expiration Date:
Month/year
I am PALS (Pediatric Advanced Life Support) certified in the U.S.A.Expiration Date:
Month/year
I am ATLS (Advanced Trauma Life Support) certified in the U.S.A.Expiration Date:
Month/year
State Licenses
For each state license you have, please provide the requested information. This worksheet has space for you to make 2 entries. You may create as many entries as needed on an additional page.
None
#1
State
License Type * Full Temporary or Limited Inactive
License Number Expiration Month Expiration Year
(License number, expiration month, and expiration year is only required if license type is “Full”)
#2
State
License Type * Full Temporary or Limited Inactive
License Number Expiration Month Expiration Year
(License number, expiration month and expiration year is only required if license type is “Full”)
Refer to attachment for additional information. (Reference as 4-a)
Medical Licensure
Has your Medical License ever been suspended/revoked/voluntarily terminated? *
No Yes Reason (up to 510 characters)
Have you ever been named in a malpractice case? *
No Yes - Reason (up to 510 characters)
Malpractice Claims History is attached (Reference as 4-b)
Is there anything in your past history that would limit your ability to be licensed or to receive hospital privileges? *
No Yes - Reason (up to 510 characters)
Have you ever been convicted of a felony? *
No Yes Reason (up to 510 characters)
Are you Board Certified?
No
Yes Board Name Expiration
1.
2.
3.
4.
5.
DEA Registration Number if applicable
Expiration Month Expiration Year:
NPI Number
Previous Training
For each internship, residency, or fellowship position you have held or currently are in, regardless of the amount of time spent there, please provide the requested information. This worksheet has space for you to make 3 entries. You may create as many entries as needed on an additional page.
None
#1
Specialty:
Type of Training: Internship Residency Fellowship
Dates of Residency/Fellowship: From: To:
Month/year Month/year
Institution/Program:
City: State/Province: Country: Years:
Program Director: Supervisor:
#2
Specialty:
Type of Training: Internship Residency Fellowship
Dates of Residency/Fellowship: From: To:
Month/year Month/year
Institution/Program:
City: State/Province: Country: Years:
Program Director: Supervisor:
#3
Specialty:
Type of Training: Internship Residency Fellowship
Dates of Residency/Fellowship: From: To:
Month/year Month/year
Institution/Program:
City: State/Province: Country: Years:
Program Director: Supervisor:
Chief Resident (only available for Fellowship Applicants)
Dates of Residency/Fellowship: From: To:
Month/year Month/year
Reason for leaving (up to 510 characters)
Was your medical education/training extended or interrupted? Please explain any gaps of 3 or more months during your medical education and / or residency training? *
No No Response
Yes - Reason (up to 510 characters)
Refer to attachment for additional information. (Reference as 5-a)
Experience(s)
For each non-residency relevant work, research, and volunteer experience/position you have had, please provide the requested information. Include non-residency clinical and teaching experience as work experiences, and include all unpaid extra-curricular activities and committees you have served on as volunteer experiences. This worksheet has space for you to make 2 entries. You may create as many entries as needed on an additional page.
None
#1
Type: Work Research Volunteer
Organization: Position: Supervisor:
Average Hours Per Week: Dates of Experience: From: To:
(Month/Year) (Month/Year)
Description (up to 1020 characters)
Reason for leaving (up to 510 characters)
#2
Type: Work Research Volunteer
Organization: Position: Supervisor:
Average Hours Per Week: Dates of Experience: From: To:
(Month/Year) (Month/Year)
Description (up to 1020 characters)
Reason for leaving (up to 510 characters)
Description (up to 1020 characters)
Reason for leaving (up to 510 characters)
Refer to attachment for additional information. (Reference as 6-a)
Publications
(Use also for Poster Sessions/Abstracts/Invited National or Regional Presentations)
For each publication/presentation you have had, please provide the requested information. This worksheet has space for you to make 6 entries.
None
#1
Title:
Authors/Presenters:
Publication/Organization:
Month: Year: Volume: Pages:
#2
Title:
Authors/Presenters:
Publication/Organization:
Month: Year: Volume: Pages:
#3
Title:
Authors/Presenters:
Publication/Organization:
Month: Year: Volume: Pages:
#4
Title:
Authors/Presenters:
Publication/Organization:
Month: Year: Volume: Pages:
#5
Title:
Authors/Presenters:
Publication/Organization:
Month: Year: Volume: Pages:
#6
Title:
Authors/Presenters:
Publication/Organization:
Month: Year: Volume: Pages:
Refer to attachment for additional publications. (Reference 6-b)
Examinations
For each examination you have taken, please provide the requested information. This worksheet has space for you to make 4 entries. (Osteopathic applicants: include the exams (COMLEX or USMLE) that lead to the medical licensure route you intend to pursue).
None
Exam #1: 1st attempt 2nd attempt
Title: Status:
(Month/Year)
Exam #2: 1st attempt 2nd attempt
Title: Status:
(Month/Year)
Exam #3: 1st attempt 2nd attempt
Title: Status:
(Month/Year)
Exam #4: 1st attempt 2nd attempt
Title: Status:
(Month/Year)
All applicants:
Language Fluency (Other than English): (255 characters)
Hobbies and Interests: (510 characters)
MedicalSchool Awards: (510 characters)
Other Awards/Accomplishments: (510 characters)
Membership in Honorary/Professional Societies: (255 characters)
Are you able to carry out the responsibilities of a resident in the specialties and at the specific training programs to which you are applying including the functional requirements, cognitive requirements, interpersonal and communication requirements, and attendance requirements with or without reasonable accommodations? *
Yes No Response No -Limiting Aspects (up to 510 characters)
Background Disclosure and Check. I understand that I must fill out a Wisconsin Background Information Disclosure (BID) form and that a background check will be performed as required by state law. The BID form is considered part of this application. I understand that I will not be employed or will be removed from employment if the employer discovers certain crimes or offenses. If I am assigned to work at another site that requires a BID form and check, I authorize UWHC to release this information to the other site.
Other Requirements. I understand that any offer of employment is contingent on successful completion of a pre-employment physical which will include mandatory pre-employment drug testing and which also may include alcohol testing. I understand the UWHC will rescind my offer of employment if I do not comply with all procedures for pre-employment drug testing. I understand that I should consider whether I wish to provide notice of my intent to end my employment with my current employer prior to successfully passing the UWHC’s pre-employment drug testing.
Federal law requires UWHC to verify the identity and work authorization of each successful candidate. Any offer of employment is contingent upon this verification.
* I understand that UWHC will use the Social Security Administration’s Verification Service (EVS) to verify my social security number after hire, if I am hired.
Authorization of Release of Information. I authorize the release of information to UWHC regarding my work history, education, licensing/certification and performance. I understand that any offer of employment is contingent upon UWHC obtaining satisfactory responses to inquires and hold harmless the companies, schools and persons from liability.
Certification of Accuracy and Completeness. I certify that all of the information provided in this application is true and complete to the best of my knowledge. I acknowledge that I may be required to verify information prior to appointment and that any omitted, false or misleading information may disqualify me from employment consideration and may be grounds for termination from employment.
Signed:______Date:______
Printed Name:______
UWHC Uniform Graduate Medical Education Application – August 2008 (for non-ERAS applicants) 1 of 8