APPLICATION FORM FOR ELECTIVE PLACEMENT

AT THE UNIVERSITY OF CAMBRIDGE

IMPORTANT:
1. Please read the information before completing this form. Please affix a
2. Receipt of this application form does not guarantee the offer of a place. passport-sized
photograph.
3. Complete the form in black ink; health section must be completed also.
4. Enclose a cheque for £200 (DO NOT SEND CASH) to cover
administrative costs, payable to the University of Cambridge.
5. Incomplete forms will not be accepted.
6. Enclose a copy of your local criminal record check.

SECTION 1 - General Information - Please complete in CAPITAL letters in black ink.

Forename: ................................................... Surname: ......................................................................

Address: ...............................................................................................................................................................

...................................................................... Country: ........................................................................

Married/Single: .................................. Male / Female: .............. Nationality: ....................................................

Date and place of birth: ........................................................................................................................................

SECTION 2 - Medical Education

Full name and address of medical school: ..........................................................................................................

.............................................................................................................................................................................

…………………………………………………………….Country: ...........................................................................

Personal e-mail address: .....................................................................................................

Summary of medical education to date (with dates). Complete on an attached sheet if necessary.

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Expected date of graduation as a doctor: ........................... month ..................... year.

SECTION 3 – Elective Preferences please list up to five choices from the list, e.g. 1.1, 2.3 etc.

Choice 1………. Choice 2 ………. Choice 3………. Choice 4 ………. Choice 5 ………..
Are you intending to do any other elective attachments in the UK?............ YES / NO

SECTION 4 - Declaration
I have read, understand, and shall comply with the paragraph on "Hepatitis B" in your information and
enclose a copy of my certificate of immunisation. I certify that I have no previous criminal convictions.

Signature: ....................................................................................... Date: ...................................................

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SECTION 5 - Dean's reference

THIS SECTION MUST BE COMPLETED BY THE DEAN OF THE APPLICANT'S MEDICAL SCHOOL

Assessment of character and conduct: ...............................................................................................................

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Assessment of academic ability: .........................................................................................................................

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Knowledge of English language: (please circle)

Written: Spoken:
Excellent Good Poor Excellent Good Poor

Declaration:
• I certify that the above applicant is in good standing with this Medical School and I support, without
reservation, this application for an elective placement at the University of Cambridge School of Clinical
Medicine.

• I confirm that he/she will be a final year medical student at the time of the elective.

• I note that a report on the student’s performance will only be completed on request and using a form
provided by my School.

• I confirm that he/she has no previous criminal convictions.

Signature: …………………………………………………………………….. Medical School Stamp:

Name (please print): ...............................…………………………………

Title: ......................................................…………………………………..

Date: …………………………………………………………………………..

Office Use Only:

Health clearance: ………………..
Dean approval: ……………………………………..

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UNIVERSITY OF CAMBRIDGE

OCCUPATIONAL HEALTH SERVICE

ELECTIVE STUDENT HEALTH QUESTIONNAIRE

PERSONAL DETAILS CONFIDENTIAL

(Please complete in BLOCK capitals in typeface or black ink)

Surname: ……………………………………………………………………………………………..

First Name: ………………………………………………Title: (Mr/Mrs/Miss/Ms)……………...…

Date of Birth: …………………………………. Nationality: ………………………………………..

Name of University : ……………………………………………………….……………………..….

Term-Time Address: …………………………………………………………………………………

Email address: ……………………………………………….. Mobile: …………………………...

Health Information

Your answers to this questionnaire will help us to ensure that your elective placement will not place
your health at risk and to determine in terms of medical fitness your suitability to work as a doctor.
Most health problems or disabilities should not prevent you from successfully training as a doctor.
However, the University does have to ensure that you are not suffering from a condition which
could make it impossible for you to learn or perform the skills necessary for you to work safely and
effectively with patients.

Please tick YES or NO for each question giving details with dates if appropriate. Please continue
on a separate sheet if necessary. If you require special aids or have special needs please give
details of these.

The information provided is treated in strict confidence.

Do you suffer or have your suffered Yes No

from the following: Details, including dates (continue on
a separate sheet if necessary)

1. Heart or blood pressure problems?

2. Epilepsy, fits or black outs?

3. Chest problems including asthma,
bronchitis, tuberculosis?
4. Skin problems including eczema,
dermatitis or psoriasis?
5. Allergies please specify?
6. Back or joint problems or disorders
affecting mobility
7. Neck, shoulder, arms, hands or
wrist problems?

Cont’d overleaf…..
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Do you suffer or have your suffered Yes No
from the following: Details, including dates (continue on
a separate sheet if necessary)

8. Glandular or metabolic disorders?

9. Stomach or bowel problems?

10. Mental health problems including
anxiety, depression, personality
disorders?
11. Eating disorders, self-harm or
overdose/attempted suicide?
12. Are you currently taking any
medication or under any medical
treatment?
13. Have you lived or worked outside
the UK in the last 5 years? Please
list the countries and time spent in
them and occupations.
14. Have you ever been in contact with
tuberculosis?
15. Have you received treatment,
including psychotherapy, from a
psychiatrist, psychologist or
counsellor for dependence on
drugs
or alcohol?
16. Do you have a disability that may
affect your ability to study or work
effectively?
17. Do you have any other condition
that may effect your ability to study
or require special arrangements?
18. Do you have any visual impairment
other than those requiring
corrective lenses?
19. Do you have hearing problems?
20. Any other significant health
problems or operations?
21. How much sick leave have you had
from University in the past 2
years?
22. How much alcohol do you drink per
week?

Medical Record

Medical records are held in confidence by the University Occupational Health Service. No medical
or other information you provide will be released without your consent being obtained but an
opinion about your fitness for clinical study in a hospital will be given to the Elective Co-ordinator.

Declaration:

The information provided is correct to the best of my knowledge. I consent to a clinical

assessment, if required.

Signed: …………………………………………………. Date: …………………………………

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