University of Pennsylvania Medical Center

UNIVERSITY OF PENNSYLVANIA MEDICAL CENTER

HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA

Occupational Medicine Residency

APPLICATION FOR RESIDENCY

POSITION BEGINNING IN
(Year) /

DATE OF BIRTH

name(Last)(first)(middle)

i am applying to the following graduate program: program description

Occupational Medicine Practicum Year, External Primary Clinical Site
Occupational Medicine Practicum Year, University of Pennsylvania Medical Center Primary Clinical Site
PERSONAL DETAILS
name(last)(first)(middle) / attach recentphotograph
optional
social security number / ecfmg registration (if applicable)
email address / fax no.
present address(street)
(city)(state)(zip)
present telephone nos.
day ( )evening ( )cell( )
number of dependents / visa status (if applicable)
permanent
temporary - specify J-1
h-1
citizenship
u.s. other
Are you a member of an ethnic minority group identified as being underrepresented in the medical sciences? Yes No
Which racial category or ethnic group do you consider yourself part of?
White, Non Hispanic White, Hispanic Black or African American, Non Hispanic Black, Hispanic American Indian/Alaska Native
Asian/Pacific Islander Other (specify) Prefer Not to Respond
permanent address: c/o (name of person through whom i can always be contacted)
(street)(city)(state)(zip) / permanent telephone no.
service obligations (national health service corps, armed forces scholarship, state programs, etc)
i am not required to fulfill any service obligations
i am committed to fulfill a service obligation beginning
(mo/yr)
number of years committed

Attachment 1. Attach curriculum vitae. This must include your activities by month and year since graduation from medical school. Your medical school graduation date must be included.

UNDERGRADUATE EDUCATION

undergraduate school(s)dates attended degree area of study
from(mo/yr) to(mo/yr) (if any)

a. name

citystate

b. name

citystate

MEDICAL EDUCATION
medical school(s) (name)
(city)(state/country)
month/year of matriculation at medical school / (month/year of graduation

honors/awards

Attachment 2. Submit a copy of your Medical School Dean’s Recommendation Letter and/or your medical school transcript.

GRADUATE EDUCATION: MPH or EQUIVALENT DEGREE

graduate school(s)dates attended
from to degreearea of study
(mo/yr) (mo/yr) (if any)

a. name

citystate

b. name

citystate

completion of core required course work GIVE:course nameuniversity (name & address)gradeyear
epidemiology:
biostatistics:
health services administration:
environmental health:
social & behavioral determinants of disease:

Attachment 3. Submit copies of all Graduate School Transcripts including documentation of successful completion of the core required coursework.

OTHER GRADUATE DEGREE EDUCATION (if any)

graduate school(s)dates attended
from tograduate degreearea of study
(mo/yr) (mo/yr) (if any)

a. name

citystate

b. name

citystate

Attachment 4 (if applicable): Submit a copy of your transcript for graduate degree education not included in the MPH or equivalent degree section.

MEDICAL residency and fellowship TRAINING

institutionpgy yearsdates attended field

from (mo/yr) to (mo/yr

institutionpgy yearsdates attended field

from (mo/yr) to (mo/yr

institutionpgy yearsdates attended field

from (mo/yr) to (mo/yr

institutionpgy yearsdates attended field

from (mo/yr) to (mo/yr

Attachment 5: Submit documentation of completion of residency training. If you are currently in a graduate-training program, you must provide a letter from the director of your current program. Note that only ACGME accredited training can be recognized as fulfilling the minimum requirements for prior training.

PRIOR BOARD CERTIFICATION

Board

YearCertification NumberExpiration Date (If Applicable)

Board
YearCertification NumberExpiration Date (If Applicable)

Attachment 6: Submit a copy of each certificate. Note that only legitimate Boards as recognized by the American Board of Medical Specialties should be included. Other “qualifications” can be described in your personal statement if desired.

NATIONAL EXAMINATIONS PASSED
i have already passed the examinations check below on the dates indicated:
nbme, part i: nbme, part ii: nbme, part iii:
(date)(date)(date)
usmle, step i: usmle, step ii: usmle, step iii:
(date)(date)(date)
flex:
(date)(state (s) of licensure)
list any additional examinations passed (fmgems, day 1; fmgems, day 2; vqe, day 1; vqe, day 2; ecfmg medical science exam:

Attachment 7. Submit copies of examination scores, i.e., documents which show you have obtained a passing score on all three parts of the National Boards, Osteopathic National Boards, or USMLE, or FLEX I and II. These documents are required by the Pennsylvania State Board of Medicine or Osteopathic Medicine in order to issue you a program required training license.

MEDICAL LICENSURE

STATE Medical License NumberExpiration Date

STATE Medical License Number Expiration Date

State Medical License NumberExpiration Date

Attachment 8 & 8a. Submit a copy of your current medical license and BLS, ATLS or ACLS certification card.(A training license is necessary to be able to see patients in the University of Pennsylvania Medical Center. Although in some cases most of your clinical work will be off-site, it may be desirable or essential for you to see patients at the University of Pennsylvania Hospital, so we require that each resident has a Pennsylvania training license). If you are accepted into the program a PA Medical Training License application will be sent to you.

personal statement

use additional sheet(s) as necessary

ADDITIONAL INFORMATION REQUIRED FROM APPLICANTS WHOSE PRIMARY CLINICAL TRAINING SITE IS EXTERNAL TO THE UNIVERSITY OF PENNYLVANIA MEDICAL CENTER

EMPLOYMENT AND PRIMARY CLINICAL TRAINING SITE
employer
address
(street)
(city)(state)(zip)
telephone nofax no.

Attachment 9: Submit detailed information on your employment site using the provided Description of Employment Site form.

Proposed Site Training Supervisor (APPLICANTS WHOSE PRIMARY CLINICAL TRAINING SITE IS EXTERNAL TO THE UNIVERSITY OF PENNYLVANIA MEDICAL CENTER ONLY)
(name)
employer
address
(street)
(city)(state)(zip)
telephone noe-mail address fax no.
Certification By American Board of

YearCertification NumberExpiration Date (If Applicable)

Certification By American Board of

YearCertification NumberExpiration Date (If Applicable)

Medical Licensure STATE Medical License NumberExpiration Date
Medical licensure State Medical License NumberExpiration Date

Attachment 10. Submit current medical licensure and required information on the enclosed Site Supervisor Information CV form for your on-site residency supervisor or preceptor. Note that your site supervisor for training purposes must be certified by the American Board of Preventive Medicine.

letters of reference. in addition to the letters from medical school dean and from director of my current training program director (if applicable),letters have been requested from the following individuals:

1. name and title

institution
address

1. name and title

institution
address

1. name and title

institution
address

NOTE: FOR APPLICANTS WHOSE PRIMARY CLINICAL TRAINING SITE IS EXTERNAL TO THE UNIVERSITY OF PENNYLVANIA MEDICAL CENTER, ONE OF YOUR LETTERS OF REFERENCE SHOULD BE FROM YOUR PROPOSED CLINICAL SITE TRAINING SUPERVISOR.

check one:

I hereby waive access to the above letters and will so inform the authors.

I desire access to the above letters and will so inform the authors.

i have read and i understand the instructions for the completion of this application. i certify that the information submitted on these application materials are complete and correct to the best of my knowledge. i understand that any false or missing information my disqualify me for this program.

signature date

type or print name

note: the signature and date on this statement must be original