Pdf checklist for non vsas and international students

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UNIVERSITY OF ILLINOIS VISITING MEDICAL STUDENTS
COLLEGE OF MEDICINE AT PEORIA Non-VSAS Students and International Students
Office of Academic Affairs (NOTE: Students from Caribbean schools are not eligible to
Box 1649 {One Illini Drive} participate in electives at UICOMP)
PeoriOa,cItlolbineori2s26, 12605062-1649 {61605}
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If your school is a participating VSAS Home School, please complete a VSAS application to apply for your preferred electives and
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ates. If your school is not a participating VSAS Home School, please submit a paper application. You may review our website at
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ww.peoria.medicine.uic.edu > Students tab > VISITING STUDENTS. There you will find the electives catalog, and other information.
plications from eligible students are processed on a first come, first served basis. Please allow 60 days for your application to
be processed. Send all required paperwork to:
Tammy L. Livingston
Office of Academic Affairs
University of Illinois College of Medicine at Peoria
1 Illini Drive
Peoria, IL 61605
Medical students from other medical schools who are in their final year may participate in fourth-year electives at the University of Illinois
College of Medicine at Peoria. Eligible students may apply for a maximum of 8 weeks of elective experience at UICOM-P. The electives
offered by each department are located under the department's section in the Electives Catalog.
There is no application fee for students from domestic schools to enroll in electives at the University of Illinois College of Medicine at
Peoria. International students pay no tuition but must pay the $300 application fee, which is non-refundable. Cafeteria meals are available
at no cost when enrolled in an elective at OSF Saint Francis Medical Center.
We are not able to offer housing to our visiting students at this time. Upon request, a list of optional housing can be forwarded
to the visiting student. Be aware that the housing information has been gathered from various sources that have used them in
the past, and is provided only for the convenience of the visiting student - UICOMP has no other information about these
housing options and has no affiliation with them.
No student will be assured placement prior to UICOM-P receiving all application components.
ELIGIBILITY: In order to apply for a fourth-year elective at the University of Illinois College of Medicine at Peoria, visiting medical students
must:
Be in their final year of medical school at the start of the requesting elective.
Attend one of the following: (1) medical schools accredited by LCME (Liaison Committee on Medical Education), (2) medical schools
accredited by AOA (American Osteopathic Association), or (3) international medical schools with an affiliation agreement with the
University of Illinois.
Be in good academic standing at the start of the elective.
Complete all core clerkships prior to the start of the elective.
Complete prerequisites (or equivalent) listed for the desired course prior to participating in the elective.
REQUIREMENTS FOR ALL STUDENTS: Visiting students must:
Provide a letter of good standing from their school.
Be covered by malpractice from their home institution (not less than $1 million per occurrence and $3 million aggregate while at the
University of Illinois College of Medicine at Peoria and its affiliated hospitals - Unity Point - Methodist and OSF St. Francis Medical
Center).
Be covered by personal health insurance from their home institution ($50,000 for each illness or accident with the deductible not to
exceed $500 per illness or accident; and for international students: $10,000 for medical evacuation and $7,500 for repatriation of
remains).
Chicago Peoria Rockford Urbana-Champaign
Tammy L. Livingston, Visiting Student Coordinator: Phone (309) 671-8412 ? Email tlliving@uic.edu ? Fax (309) 680-8605
Provide verification of the following (details can be found in the Checklist): (1) HIPAA compliance, (2) Universal Precautions Training
completed within one year prior to arrival, (3) CPR Training, (4) proof of U.S. citizenship/residency/visa status.
Fully complete all of our forms as listed on the Checklist for Students Applying through VSAS.
Provide a copy of their USMLE Step 1 or COMLEX Score. Emergency Medicine requires Step 1 or Step 2, not COMLEX.
Supply a lab coat and nametag.
Provide an evaluation form from their home institution.
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INTERNATIONAL STUDENTS:
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nly international students attending schools that have an affiliation agreement with the University of Illinois are eligible to apply for
ctives in Peoria. You may review the list of affiliated international medical schools on the UI-Chicago website at
. The only Peoria departments accepting applications from international students are (1) Family and Community
Medicine, (2) Obstetrics and Gynecology, and (3) Pathology. Please allow at least 90 days for your application to be processed.
International students pay no tuition but must pay the $300 application fee, which is non-refundable.
In addition to meeting the "Requirements For All Students," international students must also provide the following.
Submit a $300 non-refundable application fee for each elective requested. Please send payment in the form of money order,
traveler's check, or cashier's check, made payable to the University of Illinois. Payment must be in U.S. dollars. Do not send
currency.
Obtain all appropriate visas, paperwork, etc.
Send all required paperwork to: Tammy L. Livingston
Office of Academic Affairs
University of Illinois College of Medicine at Peoria
1 Illini Drive
Peoria, IL 61605
THE UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE AT PEORIA OFFERS:
Two major teaching hospitals: Unity Point - Methodist and OSF Saint Francis Medical Center, with state-of-the-art technology and a
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75-year tradition of medical education.
An extensive network of ambulatory centers and clinics.
Strong undergraduate and graduate medical education with approximately 150 medical students (M2, M3, M4), 11 residency
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programs, and 7 fellowships with more than 215 residents and fellows.
The College of Medicine, its undergraduate teaching programs, and its residencies are proud to be part of a dynamic and sophisticated
u
ownstate medical center. We are pleased to learn of your interest in Peoria. Please let us know of your interests and if you have any
estions.
Chicago Peoria Rockford Urbana-Champaign
Tammy L.Livingston, Visiting Student Coordinator: Phone (309) 671-8412 ? Email tlliving@uic.edu ? Fax (309) 680-8605
(A
Checklist for Non-VSAS and International Students
ll documentation must be submitted with the application)
Name: _____________________________________________
___ My international university is listed as an affiliated university with UIC (check website for confirmation; if your school is not
listed, you are not eligible to rotate with the University of Illinois).

Note: International Students are accepted only in the following departmental electives: Family Medicine, Pathology, and Ob/Gyn.
___ Will be in final year of training at the start of the requested elective
SCHOOL (Please check the one that applies)
___ LCME accredited ___ AOA accredited ___ International affiliated
APPLICATION
___ Section I completed by student
___ Section II completed by student's school
___ For international student, application fee paid: $300 payable in U.S. dollars to University of Illinois in the form of a money
___ S
order, traveler's check or cashier's check; neither credit cards nor cash accepted
tudent's photograph affixed to each application
LETTER OF GOOD STANDING
___ Letter of good academic standing signed by visiting student's dean
CORE CLERKSHIPS
___ Official transcript or letter from visiting student's dean verifying that each core clerkship will be completed prior to
elective.
__ Family Medicine __ Medicine __ Obstetrics/Gynecology __ Pediatrics __ Psychiatry __ Surgery
TRAINING VERIFICATIONS
___ CPR within two years prior to arrival (provide copy of current card)
___ HIPAA within one year prior to arrival
___ Universal Precautions within one year prior to arrival
FORMS
___ AAMC Standardized Immunization Form (This form must be completed, and documentation must be provided as
directed on the immunization form. Please note that your home school's record is not accepted as proof of immunity)
PERSONAL AND MALPRACTICE INSURANCE
___ Copy of personal health insurance card
___ Copy of liability insurance coverage indicating limits of liability (Proof of coverage indicating limits of liability not less than $1 million
per occurrence and $3 million aggregate)
RESIDENCY / VISA STATUS
___ International Passport provided; students can come to the U.S. on a B-1 visa
OTHER
___ ALL STUDENTS: Provide a copy of Step 1 or COMLEX score.
___ EMERGENCY MEDICINE electives: Provide a copy of Step 1 or Step 2, NOT COMLEX, score.
Visiting students are responsible for supplying their own lab coat. They pay no tuition or additional fees (except international visiting
student application fee).
Checklist
Page 2
For UICOMP use only:
___ Immunizations sent to student health for approval on ____________________________
___ Immunizations approved and received from student health
___ Acceptance letter sent to the student
___ E-Value schedule updated
___ OSF Forms sent on ________________________________
___ OSF Forms signed and received on ___________________________________
___ Unity Point Forms sent on __________________________________
___ Unity Point Forms signed and received on _______________________________
___ EPIC/Healthstream information sent
_______________________________________________________ ______________________________________________
Elective Rotation Dates
VISITING STUDENT APPLICATION
UNIVERSITY OF ILLINOIS For Non-VSAS Applicants Only
COLLEGE OF MEDICINE AT
Office of Academic Affairs
One Illini Drive; Box 1649
Peoria, Illinois 61656-1649 {Attach Passport-
RETURN ONE FORM PER ELECTIVE AND ACCOMPANYING DOCUMENTS sized Photo}
TO: Tammy L. Livingston, Academic Affairs,
University of Illinois College of Medicine at Peoria, Box 1649, Peoria, Illinois 61656-1649
SECTION I: TO BE COMPLETED BY STUDENT
Will you be an M4 at the start of this elective? No Yes
Name
First Middle Last
Address
Street City State Zip Country [if international]
Phone Pager E-mail
FOR COMPUTER ACCESS TO HOSPITAL'S MEDICAL RECORDS: Male Female Birth Date
SS# (last 4 digits) 1st Letter of Mother's Maiden Name
Are you interested in a residency at UICOM-P: No Yes Specialty
Are you interested in our student housing (subject to availability): No Yes
Clerkships you will have completed prior to the start of the elective requested:
Family Medicine Medicine Obstetrics/Gynecology Pediatrics Psychiatry Surgery
Course Number & Title for which application is made: (in rank order) Dates for which application is made: (in rank order)
1. 1.
2. 2.
3. 3.
Student's Signature Date
TO BE COMPLETED BY UICOMP OFFICE OF ACADEMIC AFFAIRS
The medical student named above has met all requirements.
Signature Date
PAGE 1
Chicago Peoria Rockford Urbana-Champaign
Tammy L. Livingston, Visiting Student Coordinator: Phone (309) 671-8412 ? Email tlliving@uic.edu ? Fax (309) 680-8605
SECTION II: TO BE CERTIFIED/COMPLETED BY DEAN OF STUDENT'S MEDICAL SCHOOL
The medical student named above:
is is not attending an institution accredited by LCME or AOA, or an international school with an affiliation agreement
is is not in good standing at this school; provide signed letter from school
will will not be in the final year of medical school at the start of the requested elective
will will not have completed clerkships as indicated above at the start of the requested elective; provide transcript
will will not pay tuition at this school during the period indicated
is is not covered by malpractice insurance that covers the University of Illinois College of Medicine at Peoria and its affiliated
hospitals (OSF St. Francis Medical Center / Unity Point Health - Methodist) while away from this school; provide proof
of limits of liability: not less than $1 million per occurrence and $3 million aggregate
is is not covered by health insurance that is in effect while away from this school; student must provide copy of insurance card
is is not HIPAA compliant; must be within one year of rotation dates; must provide proof of completion
has has not completed Universal Precautions training within one year prior to arrival; must provide proof of completion
has has not completed CPR training; student must provide copy of card
will will not be required to have an evaluation completed at the conclusion of the course; provide form if required.
is is not authorized to take this clerkship/externship
For international medical students only:
The student's school has an affiliation agreement with UIC: Yes No
The student will be registered for: 4th 5th 6th year during proposed elective
Assessment of academic ability: above average average below average
Assessment of clinical ability: above average average below average
Command of English language: above average average below average
Printed Name / Signature Title
School Phone Fax E-mail
Street City State Zip Country
SECTION III: TO BE COMPLETED BY UICOMP DEPARTMENT DESIGNEE OF ELECTIVE
The medical student named above is: approved denied for participation in the following elective.
/
Course Number -AND- Course Title Dates of Rotation
The student will report to:
[AFTER EPIC TRAINING] Name Phone E-mail
Location
Date Time
Signature Title Date
SECTION IV: TO BE COMPLETED BY UICOMP ASSOCIATE DEAN FOR ACADEMIC AFFAIRS
The medical student named above is: approved denied for participation in the above elective.
Signature Date
NOTE: Students from institutions other than the University of Illinois engaged in courses of clinical instruction at the University of
Illinois are not covered under the Self-Insurance Program for medical professional liability.
PAGE 2
November 2017
Chicago Peoria Rockford Urbana-Champaign
Tammy L. Livingston, Visiting Student Coordinator: Phone (309) 671-8412 ? Email tlliving@uic.edu ? Fax (309) 680-8605

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