Universidad Autnoma de Guadalajara

School of Medicine
Core Rotations/Electives/Pre-Internship/Internado Application
PART I STUDENT INFORMATION
Student Name (Print) _________________________________________________________
Last
First
Middle
UAG ID # ______________________

Current semester ___________________

Date of birth (month/day/year) _______________ Place of Birth ______________________

Social Security Number ____________________

E-mail Address ____________________

Nationality ______________________________

Sex: Male _______ Female _______

Home Address
__________________________________________________________________
Number
Street/Ave/Circle/Road/Lane
__________________________________________________________________
City/Town
State/Country
Zip Code
Mailing Address (if different from above)
__________________________________________________________________
Number
Street/Ave/Circle/Road/Lane
__________________________________________________________________
City/Town
State/Country
Zip Code
Home Phone Number (

) _________________Business Phone Number (

) ______________

Person to be notified in case of emergency:

Full Name _______________________________Relationship _____________________________
Home Phone Number (

) _________________ Business Phone Number (

) _______________

Address ____________________________________________________________
Number
Street/Ave/Circle/Road/Lane
_______________________________________________________
City/Town
State/Country
Zip Code

_
Revised January 2016

Have you ever been convicted of a felony in the U.S. or any foreign country? __No

___Yes

If yes, explain ___________________________________________________________________________

Have you ever been subject to any disciplinary actions in your current program? __ No __ Yes
If yes, explain ____________________________________________________________________________

I hereby certify that the information submitted in this application is complete and correct to the best of my
knowledge and belief.

_________________________
Student Signature

___________________________
Date

FOR OFFICIAL USE ONLY- DO NOT WRITE BELOW THIS LINE

Student qualified?

__ NO

__ YES

GPA _______________

Received and reviewed by:

______________________________

_________________

UAG Representative

Date

Revised January 2016

PART II -CLINICAL ROTATIONS: (APPLIES TO CURRENT 4TH, 5TH, 6TH AND 7TH SEMESTER
STUDENTS ONLY)

Student Name (Print) ______________________________________________________________________

Last
First
Middle
Check semester and fill out the rotations and location you would like to attend for the upcoming semester. For
PR Hospitals please select 3 in order of preference. Please check current school schedule for required courses.
U.S.
*Yuma, AZ (5th - 8th Semester)
*Jackson Park, Chicago, IL (5th - 8th Semester)

PUERTO RICO
*Manati Med Ctr (5th - 8th Semester)

-Saint Mary's Regional Medical Center, Reno, NV

*Sunrise, Las Vegas, NV (5th - 8th Semester)
-Mountain Vista, Mesa, AZ (5th - 8th Semester)
*Maricopa Health System, AZ (5th - 8th Semester)
-Billings Clinic, MT (5th Semester)
*St. Agnes Healthcare, MD (7th - 8th Semester)
+Aurora Health System, AZ (Psychiatry)
*Wyckoff Heights Medical Center, Brooklyn, NY (5th - 8th Semester,
And only for short term rotations, one time per student)
*CMB Approved

-CMB Approval in Process

Only 7th - 8th

*Hosp Metropolitano, Yauco
*Hosp Metropolitano, San German
*Hosp San Cristobal,Coto Laurel
*Hosp Episcopal San Lucas
*Hosp Com. Buen Samaritano,
Aguadilla
+CMB Not Approved

Core Rotations:
5th Semester: Internal Medicine 12 weeks
Family Medicine 4 weeks
Psychiatry 4 weeks
Term: ___________________________________________________________
6th Semester:
Ob/Gyn 6 weeks
Pediatrics 6 weeks
Surgery 8 weeks
Term: ___________________________________________________________
Elective Rotations:
7th Semester, 4 weeks each:
Endocrinology
Clinical Nutrition
Neurology
Infectious Diseases
Term: ____________________________________________________________

Dermatology

8th Semester, 4 weeks each:

ER
2 weeks of:

Ophthalmology

Pain Management

ENT

Trauma/Orthopedia

Geriatrics/Gerontology

Term: ____________________________________________________________________

__________________________
Students Signature

____________________
Date
Revised January 2016

PART III PRE-INTERNSHIP & INTERNADO LOCATIONS

(APPLIES TO CURRENT 8TH SEMESTER STUDENTS ONLY)

Student Name (Print) _________________________________________________________

Last
First
Middle

U.S. PRE-INTERNSHIP: Please circle 1 option

Jackson Park Hospital, Chicago, IL
Mountain Vista, Mesa, AZ
Sunrise Medical Center, Las Vegas, NV
Saint Mary's Regional Medical Center, Reno NV
Wyckoff Heights Medical Center, Brooklyn, NY (Only for short term rotations 12 weeks max/one time per
student)

PUERTO RICO INTERNADO: ( USMLE required ) Please select 3 in order of preference

__ Hospital Metropolitano Tito Mattei

__ Hospital San Cristbal

__ Hospital Metropolitano San German

__ Hospital del Maestro

__ Hospital Episcopal San Lucas Guayama

__ Hospital Pava Arecibo

__ Manat Medical Center Dr. Otero Lpez

__ Hospital Metropolitano Perea Mayagez

__ Hospital Comunitario Buen Samaritano, Inc.

__ Hospital Interamericano de Medicina Avanzada

PUERTO RICO PRE-INTERNSHIP, STARTING ON JULY 1st : ( USMLE not required )

__ Hospital Interamericano de Medicina Avanzada
__ Sistema de Salud Menonita (Deadline for submitting applications for this program is March 11th)

______________________________
Student Signature

__________________
Date

Revised January 2016

PART IV REQUIRED DOCUMENTS (MUST BE CURRENT WITHIN 1 YEAR)

Formal passport size color photo

Clear copy of valid status in the USA
-

USA Passport/Citizenship
Permanent Resident Card
Visa

Copy of USMLE Step 1 score

Malpractice insurance:
UAG will offer insurance for all hospitals (upon being admitted, Student pays to UAG)

BLS with CPR certification

New York State Department Infectious Disease and Barrier Control certication

HIPPA certication

Minimum of 2 signed letters of recommendation from UAG (applicable ONLY for Puerto Ricos
Internship)

Short white coat with UAG logo (included in graduation package)

Please scan and email all documentation in pdf format to: clerkships@uag.edu
Include : Core Rotations, Electives, or Pre-internship Application in the subject line of your email as well
as your UAG ID # in both, subject line and pdf file name.

Revised January 2016

Part V IMMUNIZATION / SEROLOGY RECORDS

Student Name (Print)
Last

________________________
First
Middle

Social Security Number________________

Contact Address___________________________________________________________________
Number
Street/Ave/Circle/Road/Lane

______

_____________________________________________________________
City/Town
State/Country
Zip Code

Home Phone Number________________

Business Phone Number _______________

To be completed and signed by a healthcare provider. All dates should include month and year.
A. EVIDENCE OF TB SCREENING COMPLETED 6 MONTHS PRIOR TO START DATE:
Date received:________________________________ Date Read:___________________________________
Result (please indicate mm of induration):__________ mm
Physician/Registered Nurse signature: ______________________________________________
License #:________________________________ State/Country: __________________________________
NOTE: If your PPD is currently positive (>10 mm) or you have a previous history, you must submit a recent
chest x-ray with a signed physician report within 11 months of the start date. Students with a history of BCG
vaccination or anti-tuberculosis therapy are not excluded from this requirement.
B. MANDATORY REQUIREMENTS:
1. Tetanus/Diphtheria (Tdap) booster within the last 10 years: Booster date: ________________
2. Measles, Mumps, Rubella, Varicella:
All students must submit copies of laboratory results of serum IgG antibody titers to measles, mumps, rubella
(MMR), and varicella. Immunization records are NOT accepted as proof of immunity. Any laboratory results
that indicate non-immunity require proof of additional vaccine administration.
Measles titer date/results: _____________________________
Mumps titer date/results: ______________________________________
Rubella titer date/results: ______________________________________
Varicella titer date/results: _____________________________________

Revised January 2016

3. Hepatitis B Series:
Documentation of three doses of hepatitis B vaccine, and a positive hepatitis B surface antibody titer is
necessary. Copy of laboratory results must be submitted.
Series #1 Date: _________

#2 Date: ___________

#3 Date: __________

Hepatitis B Surface Antibody titer date/results: _______________________________

Negative Hepatitis B Surface Antibody titer requires additional titers
-

Hepatitis B Core Antibody titer date/results: ____________________________

Hepatitis B Surface Antibody titer date/results: _________________________

Hepatitis B e antigen titer date/result: _________________________________

(Note: non-converters should repeat the series in an attempt to show immunity)

Known Hepatitis B carriers must show copies of the following laboratory results:
- Hepatitis B Surface Antibody
- Hepatitis B Surface Antigen
- Hepatitis B Core Antibody
- Hepatitis B e Antigen
4. Influenza vaccine (within 1 year)
Date received: ________________________________
I have been asked to evaluate
and certify that the student is free from any
health impairment which is of potential risk to patients or may interfere with the performance of his/her duties.
This includes habituation or addiction to depressants, stimulants, narcotics, alcohol, or other drugs or substances
that may alter the individuals behavior.
__________________
Physician Signature

___

__________________
___
Physician Name (Please Print)

_____________
Date

__

_____________
Country or State License #

__

Address:
City:

State/Country:

Zip Code:

Revised January 2016