UCD SCHOOL OF MEDICINE AND MEDICAL SCIENCE
VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS
PAGES 2-7 to be completed once a placement at UCD is offered
(month/day/year)
1.
Date of Application
2.
Last Name (Family/Surname)
3.
First Name
4.
Home Address (street, city, state, postal code, country)
5.
Home Phone Number
6.
Email Address(es)
7.
(
Male
Female)
Emergency Contact
(Name, Relationship, Phone Number)
8.
Date & Place of Birth
9.
Citizenship
10.
First Language
11.
English Skill (fluent; good; fair)
12.
TEFL Score (enclose official score report)
(Required for schools where English is not teaching language)
13.
Your Medical School Name/Location
14.
Degree you will Earn (e.g. MD or MD/PhD)
15.
Is your Medical School a member of Universitas 21
16.
Expected Graduation Date
17.
Date to Begin Placement at UCD
18.
# of Months to Spend at UCD
19.
Please Describe Your Academic Background & Interests (~ 1 page)
20.
21.
IMPORTANT: LIST FACULTY @ UCD WITH WHOM YOU WOULD LIKE TO TRAIN:
(month/day/year)
(month/day/year)
Complete Form: Once you have completed this form electronically, please save and attach in an email to
international.medicine@ucd.ie along with CV and personal statement. If we are able to find a placement for
you, UCD coordinator will send you instructions for the provision of documents required to complete this
UCD SCHOOL OF MEDICINE AND MEDICAL SCIENCE
VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS
PAGES 2-7 to be completed once a placement at UCD is offered
application (see below).
22.
Checklist of Documents Required to Complete Application
(only if UCD – succeeds in placing you)
medical school certification and student attestation
proof of personal health insurance that will cover
you while in Ireland
immunization record (in English; see following page)
GARDA clearance form (form will be provided by UCD SMMS)
Police clearance from the country of origin
official copy of TEFL score report (not required
if English is the teaching language of the home medical school)
International Medical School Official Certification
for completion by Dean/designated official of student’s home medical school
STUDENT:
Last Name :
First Name:
This is to certify that the medical student named above is in good standing at this institution and will be returning
to this institution to complete medical studies. This further certifies that the information provided on this
application is correct, and that the student does have our permission to engage in research/clinical activities at
the University College Dublin, School of Medicine and Medical Science. The student has completed the
equivalent of UCD bachelor’s degree (a minimum of four years of post-secondary school education). The student
is covered by personal health insurance (attach proof) which covers the student while away from our school and
in Ireland. In addition, the signature below serves to certify that we have no record of this student’s ever having
engaged in criminal activity of any kind.
MEDICAL SCHOOL OFFICIAL: Last Name :
First Name:
Official Title:
Medical School Name:
Email Address:
Location: (city/country)
Is instruction at your medical school in English?
Yes
No
(if English is not the principal language of instruction, student’s TEFL exam results must be provided)
Signature of Medical School Official
Date
UCD SCHOOL OF MEDICINE AND MEDICAL SCIENCE
VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS
PAGES 2-7 to be completed once a placement at UCD is offered
Student Attestation & Behavioural Agreement
please check each item and sign at the end of this section
The information I have provided in my application form and all attachments is accurate. If I am accepted at UCD,
I understand that I remain a student in my home school
I will respect the confidential nature of all medical records and personally identifiable information related to patients
I will act prudently within the limits of my knowledge, experience, and training; follow policies related to procedures and
etiquette; and wear attire acceptable to UCD School of Medicine and Medical Science
I shall respect all property belonging to UCD and its affiliated institutions and I understand that Í will be responsible for the
repair or replacement of any property damaged or destroyed by me
I will be responsible for my own housing and transportation to and from UCD School of Medicine and Medical Science and
UCD affiliated hospitals
I understand that if I am unable to attend scheduled activities, I must notify the School of Medicine and my home school
I agree to abide fully by the University College Dublin Code of Conduct http://www.medicalcouncil.ie/PublicInformation/Professional-Conduct-Ethics/ ; http://www.ucd.ie/registry/academicsecretariat/docs/student_code.pdf and Code
of Academic Integrity http://www.ucd.ie/t4cms/ucd_policy_on_plagiarism_and_faq.pdf and abide by all laws and other
relevant legal conditions surrounding the program
I will conduct myself in accordance to the highest personal standards of character and integrity and not engage in any
behaviour that is deemed as inappropriate or unacceptable by the head of laboratory/internship supervisor or an authority
of the UCD School of Medicine or the University College Dublin
I will actively engage in the practice of good personal safety behaviours
If in the opinion of the head of laboratory/internship supervisor or an authorized officer of the School, I am found to be in
non-compliance of this agreement, I understand that my volunteer experience may be terminated immediately
_________________________________
Signature of Medical Student
Date
APPLICANT NAME: Last
First
BIRTHDATE
http://www.ucd.ie/medicine/lifewithus/studentlife/currentstudents/programmerequirements/
UCD School of Medicine requires all of the information listed below for a student to be considered for placement. *Quantitative results
require lab reports indicating titer and reference range. This form must be completed, signed and dated by a health care provider.
Applicants should be free from symptoms of infectious disease upon arrival. Applicant: If you become ill with a communicable disease
while at UCD, you must notify your course director/mentor.
MEASLES, MUMPS, RUBELLA (MMR)
Two doses of MMR are required (1st dose must be administered after the 1st birthday and 2nd dose a minimum of 4 weeks later).
Students who have not had MMR as specified may satisfy this requirement with the alternate regimen listed below OR positive titers
MMR Dose 1 ____/____/____ Dose 2 ____/____/____
Alternative regimen OR positive *titer verifying immunity
MEASLES
MUMPS
Dose 1 ____/____/____ Dose 2 ____/____/____
Dose 1 ____/____/____
OR
OR
RUBELLA Dose 1 _____/____/____
OR
*Titer quantity _________
Lab report attached
*Titer quantity _________
Lab report attached
*Titer quantity _________
Lab report attached
HEPATITIS B Requirement: Three doses (doses one and two given four weeks apart, and the third dose at least 4 to 6 months after the
first dose) AND a blood test showing *titer quantity/quantitative result (lab report, indicating titer and reference range required).
Dose 1 ____/____/____ Dose 2 ____/____/____ Dose 3 ____/____/____ AND *Titer quantity _________
Lab report attached
______________________________________________________________________________________________________________
VARICELLA (Chicken Pox) Requirement: Two doses of chicken pox vaccine are required at least one month apart (must be administered
after 1995) OR positive *titer verifying immunity (for positive titers, lab report including reference range, is required).
Dose 1 ____/____/____ Dose 2 ____/____/____ OR *Titer quantity _________
Lab report attached
_______________________________________________________________________________________________________________
TETANUS-DIPHTHERIA and PERTUSSIS (Tdap) Requirement: One dose
Dose 1 ____/____/____
________________________________________________________________________________________________________________
POLIO Requirement: Student must have completed primary series of polio immunizations – note below date series was completed.
Oral Polio Vaccine (OPV) ____/____/____
OR
Enhanced Inactivated Polio Vaccine (E-IPV) ____/____/____
________________________________________________________________________________________________________________
TTBI (Test of Tuberculosis Infection) Requirement: Two PPDs OR one QuantiFERON/IGRA, all within 12 months of the requested
elective start date (regardless of prior vaccination with BCG). Any student with a positive TTBI must include with this application reports
of the positive reaction, subsequent chest x-ray, and a TB symptom check done within 12 months of the elective start date.
Dates and results of last two PPD tests: ____/____/____
Negative
Positive ____/____/____
Date and result of QuantiFERON/IGRA blood test for TB infection ____/____/____
Negative
**Reminders**
1) Both PPDs must be done 1 year or less before the elective start date.
2) TTBI (PPD or QuantiFERON/IGRA) positive? If yes, check box and attach radiology report:
Negative
Positive
Positive OR
INFLUENZA Requirement: Students must have current influenza vaccine(s)
Flu Vaccine Date ____/____/____
Health Care Provider
Print Name_____________________________________________________________
Phone #______________________________
Signature_______________________________________________________________
Date_________________________________
Address________________________________________________________________________________________________________
ADULT CONSENT STATEMENT (age 18 or older)
I, ________________________________________________, understand and consent as follows:
Print First and Last Name
1. I have been offered a volunteer placement opportunity within the School of Medicine and
Medical Science for educational/training purposes.
2.
I understand that medical sites are specialized environments in which chemicals, biological
materials, and special instruments are often used, which can have the potential for creating
hazardous conditions. I agree to follow supervision in order to reduce such risk. I am aware
of the potential for such risk.
3. In the event of any emergency occurring during my volunteer experience, I grant permission
to UCD, its physicians, members of the faculty, agents and employees to provide such
emergency care and treatment as in their judgment may be deemed necessary or advisable.
I agree to cover the cost of such emergency care and treatment, if any.
4. I accept responsibility for providing any treatment or care I might require beyond emergency
treatment.
Signed: ____________________________________
Signed (witness):_____________________________
Date: ______________________________________
Date: _____________________________________
PARENTAL CONSENT STATEMENT FOR MINORS (under age 18)
As the undersigned parent/guardian of ________________________________________________, I
understand and consent as follows:
Print Minor Student’s Full First and Last
Name
1. My child has been offered a volunteer placement opportunity within the School of Medicine
and Medical Science for educational/training purposes.
2. I understand that medical sites are specialized environments in which chemicals, biological
materials, and special instruments are often used, which can have the potential for creating
hazardous conditions. I am aware of the potential for such risk.
3. In the event of any emergency occurring during my child’s volunteer experience, I grant
permission to UCD, its physicians, members of the faculty, agents and employees to provide
such emergency care and treatment as in their judgment may be deemed necessary or
advisable. I agree to cover the cost of such emergency care and treatment, if any.
4. I accept responsibility for providing any treatment or care my child might require beyond
emergency treatment.
Name of Parent/Guardian: (Please print full name):
_________________________________________________
Signed: ____________________________________
Signed (witness):_____________________________
Date: ______________________________________
Date: ______________________________________