Office of Student Services
Stanford University School of Medicine
Senior Elective Application
Student Name: _________________________________________________________
Quarter Applying: _______________________________________________________
Name of Medical School: _________________________________________________
This applicant is a currently registered senior year student in the M.D. or D.O. degree program at the school listed above, which is accredited by the Liaison Committee on Medical Education or Education Department of the American Osteopathic Association.
The student is approved to take an elective at Stanford University School of Medicine.
The student is covered by malpractice insurance by the school above. Indicate the limits of the coverage:
$___________ Per Occurrence (minimum requirement is $1,000,000)
$___________ Aggregate (minimum requirement is $3,000,000)
- Yes / No Student has been trained on Bloodborne Pathogens.
Yes / No Student has been trained on patient privacy and data security, understands the requirements of HIPAA, and has had no compliance issues with such rules.
Yes / No Student has passed USMLE Step 1 or COMLEX Level 1.
Yes / No Student will have completed the core clerkships in Medicine, Pediatrics, and Surgery by the time of the elective.
- Circle any other core clerkships the student will have completed by the time of the elective
Ambulatory Medicine | Critical Care | Family Medicine | Neurology | Ob/Gyn | Psychiatry
Note: The student is responsible for delivering evaluation forms directly to the clerkship coordinator or director. If a confirmation of the scheduled elective is required by the home school, please send the form along with the application. It will be returned when scheduling is complete.
(Dean of student's
Important: Please affix
or stamp school seal here ---->