Dean's Statement
Office of Student Services
Stanford University School of Medicine

Visiting Senior Elective Application

Student Name: _________________________________________________________

Quarter Applying: _______________________________________________________

Name of Medical School: _________________________________________________

1. 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.

2. The student is approved to take an elective at Stanford University School of Medicine.

3. 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)

4. Yes  /  No   Student is HIPAA compliant.

5. Yes  /  No   Student has passed USMLE Step 1 or COMLEX Level 1.

6. Yes  /  No   Student will have completed the core clerkships in Med, Peds, and Surg by the time of the elective.

7. 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.

Signature: _____________________________________________________
               (Dean of student's home school)

Title: __________________________________________________________

Date: _________________________________________________________

Important: Please affix or stamp school seal here ---->