APPLICATION CHECKLIST Students applying for electives must be in their final year of medical school and indicate that

the elective is to be taken FOR CREDIT at the parent institution. YOU MUST submit the items on the checklist at the time of application. An INCOMPLETE APPLICATION will be returned to the students home institution. PERIOD DATES for 2011-12 ACADEMIC YEAR: 1 4 7 10 5/9/11 6/5/11 8/1/11 8/28/11 10/31/11 11/27/11 1/30/12 2/26/12 2 5 8 11 6/6/11 7/3/11 8/2/11 9/25/11 11/28/11- 12/22/11 2/27/12 3/25/12 3 6 9 12 7/4/11 7/31/11 9/26/11 10/23/11 1/3/12 1/29/12 3/26/12 4/22/12

A complete application will include the following items: APPLICATION FORM: Individual application must be submitted for EACH elective to which you are applying. A complete form will include both student and institution information. Must include institutional school seal affixed to the official application. PLESE NOTE: The application process may not be circumvented by arrangements with an individual member of the UPSOM faculty. APPLICATION FEE: Non-refundable application fee of $25.00 is assessed for each elective application; payable via credit card at the time of the request for an application. LETTER OF GOOD STANDING: Your institution must verify that you will be a fourth year medical student in good standing at the time of the elective and be taking the elective for credit at the students home institution. VERIFICATION OF HIPPA/STANDARD PRECAUTIONS AND CRP: Verifications of training, as well as dates of training are required for HIPPA, Standard Precautions and CPR trainings. PROOF OF HEALTH INSURANCE COVERAGE: Provide documented proof of personal health insurance coverage (PHOTOCOPY OF HEALTH CARD). PROOF OF MALPRACTICE/LIABILITY COVERAGE: Minimum requirement is $1M per occurrence/$3M in aggregate. Acceptable proof is either a certificate of insurance or a statement by your institution in their letter of good standing. IMMUNIZATION RECORD: Complete Immunization with appropriate signature. (either primary care physician or student health official) Any missing immunizations make the application incomplete and it will be returned to the students home institution. CRIMINAL BACKGROUND CHECKS LISTED BELOW within one (1) year for the date of the actual elective. (Must be included in APPLICATION PACKET) PENNSYLVANIA STATE CRIMINAL BACKGROUND CHECK/ACT 34 ($10.00 FEE) Form may be completed online. http://www.portal.state.pa.us/portal/server.pt?open=512&objID=4451&PageID=458621&mode=2

PENNSYLVANIA STATE CHILD ABUSE CLEARANCE/ACT 33 ($10.00 FEE) http://www.dpw.state.pa.us/findaform/childabusehistoryclearanceforms/index.htm Students should check the CHILD CARE box on the Purpose of Clearance section. MAIL FORM TO THE ADDRESS AT THE TOP OF THE FORM. FBI FINGERPRINTING CLEARANCE/ACT 73 http://www.pa.cogentid.com/index.htm SELECT: PUBLIC WELFARE $33.00 fee. Pennsylvania residents must provide clearance in application packet. If you are out of state, you are able to register on line for Act 73. You must provide proof of receipt of payment as this clearance cannot be obtained until you arrive if Pennsylvania. Upon arrival and check in at the Student Affairs Office you will be directed to the nearest COGENT site to have your fingerprints processed. (Please note: If you are applying to a Pediatric Elective you must forward the clearances to Marlynn Haigh as well)

SUPPLEMENTAL REQUIREMENTS: Several of our clinical departments required additional information and/or documentation for consideration of acceptance. Please review the information below and when appropriate forward documents to the department directly. Anesthesiology: Faculty letter and statement from the student, stating why they want to do an elective in anesthesia at Pitt. Mail to: Ms. KATHY LEE FOON, Elective Coordinator, Department of Anesthesiology, 3471 Fifth Avenue, 910 Kaufmann Building, Pittsburgh, PA 15213 Dermatology: Resume or CV. Mail to: MS. CINDY MCINTYRE, Elective Coordinator, Department of Dermatology, Biomedical Science Tower, Suite W1041, 3501 Fifth Avenue, Pittsburgh PA 15260 Internal Medicine: Faculty letter of recommendation. Mail to: MS. THERESA CULLENS, Elective Coordinator, Department of Internal Medicine, 3459 Fifth Avenue, Room N 713 MUH, Pittsburgh PA 15213 Neurological Surgery: Resume or CV & two (2) letters of recommendation from faculty. Mail to: MS. MELISSA LUKEHART, Elective Coordinator, Department of Neurological Surgery, 200 Lothrop Street, Suite B461, Pittsburgh, PA 15213 Pediatrics: Copy of students transcript up to current third year grades; statement form student noting the number of times the USMLE step 1 exam was taken and a copy of scores. Mail to: MS. MARLYNN HAIGH, Elective Coordinator,Department of Pediatrics, One Childrens Place, 4401 Penn Avenue, 3rd Floor Faculty Pavillion, Pittsburgh PA 15224 or email: Marlynn.Haigh@chp.edu. Contact Ms. Haigh directly regarding Childrens Background Check policies. Surgery: Each application will be reviewed by the Director of Senior Surgery Rotations. The following documents are required for review: Curriculum Vitae, unofficial transcript and letter of recommendation from third year surgery clerkship Course Director indicating your performance on the rotation. These supplemental documents should be mailed directly to the department. MS. KATHY HAUPT, Medical Student Coordinator, PO Box 7533, Room F675 PUH, Pittsburgh PA 15213