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Medical Student Clerkship Application

 

To apply for a rotation, please enter your information in the form below and submit. Following submission, send your CV or résumé to thomrene@isu.edu. If you have any questions, please contact the administrator at (208) 282-4713.

Personal Information












Medical School Information


  
  Year you will be during this rotation
  Anticipated graduation date

Rotation Coordinator Information

Please enter the requested information for the student rotation coordinator at your medical school.












Rotation Information



* Limited to student applicants from the University of Washington and University of Utah only
If Clinical Elective, please describe your rotation objectives and preferences.

  First Choice
  Second Choice
  Third Choice
Would you like to have on-campus housing arranged for you?
  
What experience and/or rotations have you completed in family medicine or rural medicine thus far?

Please explain your interest in family medicine:


Additional Information

Are you currently in good standing with your medical school program?
  
If not, please explain:


If you have not taken this test, put a dash in the score box.
USMLE Step 1:              Score

USMLE Step 2:              Score

COMLEX Step 1:              Score

COMLEX Step 2:              Score

Class Rank:  

GPA:  

High honors, honors, courses passed/failed:


Have there been any disciplinary and/or remedial actions taken against you while in medical school?
  
Have you ever been charged with or convicted of a felony or misdemeanor other than minor traffic violations?
  
If you answered "yes" to either question above, please explain:

Do you currently have or have you had any serious physical or mental condition in the past five (5) years that in any way impairs or limits your ability to practice medicine with reasonable skill and safety?
  
Do you currently have or have you had problems with the use of alcohol, stimulants, habit-forming and/or illegal drugs in the past five (5) years that in any way impair or limit your ability to practice medicine with reasonable skill and safety?
  
If you answered "yes" to either question above, please explain:

Will you be bringing family with you?
  
Do you have any ties to Southeastern Idaho?
  
If so, please explain:


Are you interested in applying for residency here?
  
If yes, would you like an interview scheduled during your rotation (4th-year students only)?
  


REMINDER:  Please e-mail your CV or résumé to Renée Thompson at thomrene@isu.edu.

IDAHO STATE UNIVERSITY

921 South 8th Avenue
Pocatello, Idaho, 83209