12-22-2004, 02:51 AM
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Application For Internal Medicine Observership
To be completed by applicant
APPLICANT INFORMATION:
Name
Address
Phone
SS#
Date of Graduation
MEDICAL SCHOOL INFORMATION:
Name
Address
Phone
Fax
Candidate Email
Internal Medicine Rotation Request Rotation Period: ______________________________
0 YES 0 NO Are you applying to the Synergy Medical Internal Medicine Residency Program?
0 YES 0 NO Have you passed USMLE Step 1?
0 YES 0 NO Have you passed USMLE Step 2?
0 YES 0 NO Have you passed your CSA exam? Expected date of exam: _________________
0 YES 0 NO Are you currently within the U.S.?
0 YES 0 NO Will you require housing information?
0 YES 0 NO Do you have personal health coverage, which will be in effect during this
experience?
0 YES 0 NO Have you had all immunizations recommended by CDC? (please see attached)
0 YES 0 NO Have you had a negative PPD skin test within the preceding 12 months?
Date of test: _____________________
0 YES 0 NO Have you had a serology test showing immunity to rubella?
0 YES 0 NO Have you received the hepatitis B vaccine series?
0 YES 0 NO Have you had a physician documented case of varicella or have had a serology
test showing immunity to varicella?
0 YES 0 NO Do you have acute or chronic health problems? Explain.
_______________________________________________________________
_______________________________________________________________
______________________________ _______________________________ ____________
Print Name Signature Date
Return completed application to:
Sheila Duby, Residency Administrative Assistant
Synergy Medical Education Alliance
formally known as Saginaw Cooperative Hospitals, Inc.
1000 Houghton Avenue, Suite 1100
Saginaw, MI 48602
Phone: (989) 583-6826 Fax: (989) 583-6840
Immunization Requirements
Measles (Rubeola)
· If born before 1957 - one dose of live measles vaccine/MMR OR a titer
· If born in or after 1957, two doses of live measles vaccines administered 1 month apart OR
· 1 dose of measles vaccine/MMR followed by a titer about 6 weeks later and if positive, no further vaccination. If negative, 1 additional dose of measles vaccine/MMR OR
· Physician-diagnosed/documented measles
Mumps
· If born before 1957, considered to be immune.
· If born in or after 1957, one dose of mumps vaccine/MMR administered on or after the first birthday OR
· A titer OR
· Physician-documented mumps
Rubella (German Measles)
· One dose of rubella vaccine/MMR administered on or after the first birthday or
· A titer
Varicella (Chicken Pox)
· 2 Doses of varicella vaccine administerd 4-8 weeks apart OR
· A titer OR
· Physician-documented varicella
Tetanus/Diphtheria (Td)
· Must have every ten years
Polio
· Documentation of immunization (live or inactivated vaccines). (IPV=2 doses given 4-8 weeks apart followed by 3rd dose 6-12 months after 2nd dose. Booster doses may be IPV or OPV)
Tuberculin Skin Test
· Negative Skin Test Yearly
· Documentation if prophylactic treatment if tested positive
Hepatitis B
· Must provide documentation of: Serologic evidence of immunity - titer. &nb
Application For Internal Medicine Observership
To be completed by applicant
APPLICANT INFORMATION:
Name
Address
Phone
SS#
Date of Graduation
MEDICAL SCHOOL INFORMATION:
Name
Address
Phone
Fax
Candidate Email
Internal Medicine Rotation Request Rotation Period: ______________________________
0 YES 0 NO Are you applying to the Synergy Medical Internal Medicine Residency Program?
0 YES 0 NO Have you passed USMLE Step 1?
0 YES 0 NO Have you passed USMLE Step 2?
0 YES 0 NO Have you passed your CSA exam? Expected date of exam: _________________
0 YES 0 NO Are you currently within the U.S.?
0 YES 0 NO Will you require housing information?
0 YES 0 NO Do you have personal health coverage, which will be in effect during this
experience?
0 YES 0 NO Have you had all immunizations recommended by CDC? (please see attached)
0 YES 0 NO Have you had a negative PPD skin test within the preceding 12 months?
Date of test: _____________________
0 YES 0 NO Have you had a serology test showing immunity to rubella?
0 YES 0 NO Have you received the hepatitis B vaccine series?
0 YES 0 NO Have you had a physician documented case of varicella or have had a serology
test showing immunity to varicella?
0 YES 0 NO Do you have acute or chronic health problems? Explain.
_______________________________________________________________
_______________________________________________________________
______________________________ _______________________________ ____________
Print Name Signature Date
Return completed application to:
Sheila Duby, Residency Administrative Assistant
Synergy Medical Education Alliance
formally known as Saginaw Cooperative Hospitals, Inc.
1000 Houghton Avenue, Suite 1100
Saginaw, MI 48602
Phone: (989) 583-6826 Fax: (989) 583-6840
Immunization Requirements
Measles (Rubeola)
· If born before 1957 - one dose of live measles vaccine/MMR OR a titer
· If born in or after 1957, two doses of live measles vaccines administered 1 month apart OR
· 1 dose of measles vaccine/MMR followed by a titer about 6 weeks later and if positive, no further vaccination. If negative, 1 additional dose of measles vaccine/MMR OR
· Physician-diagnosed/documented measles
Mumps
· If born before 1957, considered to be immune.
· If born in or after 1957, one dose of mumps vaccine/MMR administered on or after the first birthday OR
· A titer OR
· Physician-documented mumps
Rubella (German Measles)
· One dose of rubella vaccine/MMR administered on or after the first birthday or
· A titer
Varicella (Chicken Pox)
· 2 Doses of varicella vaccine administerd 4-8 weeks apart OR
· A titer OR
· Physician-documented varicella
Tetanus/Diphtheria (Td)
· Must have every ten years
Polio
· Documentation of immunization (live or inactivated vaccines). (IPV=2 doses given 4-8 weeks apart followed by 3rd dose 6-12 months after 2nd dose. Booster doses may be IPV or OPV)
Tuberculin Skin Test
· Negative Skin Test Yearly
· Documentation if prophylactic treatment if tested positive
Hepatitis B
· Must provide documentation of: Serologic evidence of immunity - titer. &nb