S CHOLARLY Y EAR R EQUEST F ORM
The Scholarly Year program at Mount Sinai School of Medicine is available to students who have completed their second or third year and choose to devote a year to conducting research or working on another type of scholarly project. This endeavor, which may be conducted either at Mount Sinai or another site, offers students a more intensive research experience than otherwise possible.
Students considering a Scholarly Year should consult with their advisor and with the Medical Student Research Office (MSRO) to discuss their plans. The Scholarly Year Request must be approved by the MSRO (Dr. Zier or Dr. Wyatt) before submission to the Registrar. Until your request for a Scholarly Year has been approved by the Registrar, you will be considered in the appropriate MD class. Students who have not been approved for a Scholarly Year at the end of the academic year and who have not registered for rotations or clerkships will automatically be placed on administrative leave. This may impact your student privileges, including eligibility for housing. Those who have registered for rotations or clerkships will be expected to carry out all assigned duties at their clinical sites.
CLEARANCE TO BEGIN SCHOLARLY YEAR: Students who leave school prior to completion of the degree requirements must obtain clearance before departure. The student will receive a letter of leave and individualized conditions will apply. All students must meet the criteria and confirm agreement with the terms of the leave in writing. In addition, students must complete the sign-out form below requiring the signatures of a number of offices indicating that there are no outstanding debts or other encumbrances to the student's record and that all medical school property has been returned. When all the signatures are obtained, the student must return the form to the Registrar.
REQUIRED SIGNATURES :
All students must obtain advisor’s signature, indicating that s/he approves of your plans
Advisor
After this, please get signatures from the following offices:
Financial aid office – Annenberg 5-05 Ph: (212)241-5245
Bursar – Annenberg 5-05 Ph: (212)241-5245
Levy library – Circulation Desk, Annenberg 11 Ph: (212)241-7791
Realty – 1249 Park Ave, 1st Floor Ph: (212)410-0307
International students must also obtain clearance from the International Personnel Office, Division of
Human Resources
Final approval:
Dr. Karen Zier - Annenberg 13-30 Ph: (212)241-4429
Or, Dr. Christina Wyatt – Annenberg 23-74 Ph: (212)241-6689
Registrar – Annenberg 13-30 Ph: (212)241-6691
SUBMITTING THIS FORM:
All students planning a Scholarly Year must submit the following:
Scholarly Year Request form
Academic Requirements form
In addition, if you are doing an:
Externally funded research program:
Letter of acceptance to an externally funded research program
If you are doing the:

Doris Duke Clinical Research Fellowship Program

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
Medical Research Scholars Program

Sarnoff Foundation Program

CDC Experience Applied Epidemiology Fellowship

Fogarty International Clinical Research Scholars Program

NIH Year Off Training Program for Medical Students
Internally funded research project (SYNERGISM Program):
If you are doing any other type of research Scholarly Year, which is one that is arranged by you with a mentor or a department here or at another institution and not one of the programs above under externally funded research program, you must submit:
Mentor’s letter of support (send to medicalstudentresearch@mssm.edu
);
Research proposal following guidelines at http://tinyurl.com/3f7oepu (send to medicalstudentresearch@mssm.edu
); and
‘Source of Funding form,’ with notarized signatures if support is coming from anyone other than the mentor
Global Health Institute funded project
Signature from Global Health leadership
Degree granting program:
Letter of acceptance
Financial support arrangements
STUDENT STATUS:
Students who go on Scholarly Year are considered full-time students and maintain access to regular student resources.
INTERNATIONAL STUDENTS: International students must obtain clearance from the International Personnel Office,
Division of Human Resources. For more information, contact Hasan Shroff, Senior Immigration Specialist: hasan.shroff@mountsinai.org
.
TUITION:
There is a $100 fee for students going on a Scholarly Year. Please contact Phillip Parke, Bursar, for questions: phillip.parke@mssm.edu
.
FINANCIAL AID: Loans are not available for students on Scholarly Year. Contact Dale Fuller for more information: dale.fuller@mssm.edu
.
HOUSING: Students on Scholarly Year are eligible for housing. Contact Angela Moura at angela.moura@mssm.edu
to file the appropriate paperwork.
HEALTH INSURANCE: Health Insurance is required for Scholarly Year. Students attending another institution can remain with Mount Sinai student health insurance or, if the student decides to accept other insurance, they must cancel Mount Sinai health insurance within 30 days of start date. Students must remain with their student health insurance and cannot receive
Mount Sinai employee health benefits if paid a salary. For more information, contact Leonara Dasu in Enrollment Services:
Leonara.Dasu@mssm.edu
.
LIBRARY PRIVILEGES: L ibrary privileges are available for students on Scholarly Year or IEP. Please go to the Circulation Desk in Levy library (Annenberg 11) for information and to get clearance for your leave.
FOR MORE DETAILED GUIDELINES, go to: http://tinyurl.com/ScholarlyYearGuidelines

One Gustave L. Levy Place
Annenberg Building Room 13-30
Box 1257
New York, NY 10029-6574
Phone: (212) 241-6691
Facsimile: (212) 369-6013
E-mail: Registrar@mssm.edu
S CHOLARLY Y EAR R EQUEST F ORM
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S TUDENT INFORMATION
Student Name (First, Middle Initial , Last) Class of:
Forwarding Address (please also update directory on Webed)
Life Number
City State Zip
Program
Requested Start Date:
Telephone Number
Email
Anticipated Return Date:
HOME CELL
P ROJECT I NFORMATION
Mentor Name
Institution/
Address
Title of Project
City
Telephone Number
Sponsoring Agency (if any)
State Zip
HOME CELL
If pursuing a degree,
Degree and institution
Date degree expected
If doing any research program other than the ones listed on page 1 under externally funded research programs,
you must submit a research proposal as part of requesting approval from the Medical
Student Research Office (Dr. Zier or Dr. Wyatt)
Student Signature
Student Affairs Advisor (name and signature)
Date
Date
Global Health Institute (name and signature)
Only if a Global Health funded project
P LE ASE OBTAIN CLE ARAN CE FROM THE DEPARTMENTS LISTED BELOW
Financial Aid: Dale Fuller (x4-5245)
Annenberg 5-05
Bursar: Phillip Parke (x4-5245)
Annenberg 5-05 $100 matriculation fee paid
Date
Date
Date

One Gustave L. Levy Place
Annenberg Building Room 13-30
Box 1257
New York, NY 10029-6574
Phone: (212) 241-6691
Facsimile: (212) 369-6013
E-mail: Registrar@mssm.edu
S CHOLARLY Y EAR R EQUEST F ORM
C ONT
’
D P LE ASE OBTAIN CLEARAN CE FROM THE DEPARTMENTS LISTED BELOW
Date Levy Library:
Circulation Desk
Annenberg 11
Real Estate: Angela Moura
1249 Park Avenue, 1st Floor
International Personnel Office, Division of Human Resources
Hasan Shroff
320 East 94th St, 5th Floor
Date
Date
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F INAL A PPROV AL
T HE ABOVE NAMED STUDE NT HAS BEEN APPROVED FOR LEAVE FOR THE ABOVE DATES
C OMMENTS (I.
E .
S TEP II CS EXTENSIONS ):
Registrar: Nelson Pe
Annenberg 13-30
Student returned Mount Sinai ID
N/A
Dean/Program Director
Dr. Karen Zier, Associate Dean for Medical Student Research,
Director, Medical Student Research Office; or
Dr. Christina Wyatt, Associate Director, Medical Student Research Office
Date
Date

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One Gustave L. Levy Place
Annenberg Building Room 13-30
Box 1257
New York, NY 10029-6574
Phone: (212) 241-6691
Facsimile: (212) 369-6013
E-mail: Registrar@mssm.edu
S CHOLARLY Y EAR A CADEMIC R EQUIREMENTS
B OARD D ATES
P LE ASE GIVE THE DATES WHEN YOU WILL TAKE THE BOARDS .
I F YOU HAVE ALREADY T AKEN ANY USMLE EXAM ,
PLEASE ENTER THE DATE BELOW
Step 1 date: ___________________________
Step 2ck date (must be taken before your Scholarly Year): _________________________
Step 2cs date (same date as your original entering class): _________________________
A GREEMENT
I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO NOTIFY THE R EGISTRAR AND S TUDENT A FFAIRS OF ANY CHANGES IN
BOARD DATES .
S TUDENTS WHO FAIL TO DO SO WILL AUTOMATIC ALLY BE PLACED ON ADMINISTRATIVE LEAVE AND THIS
LEAVE CHANGE WILL BE PERMANENTLY DOCUMENTED IN THE MSPE AND TRANSCRIPT .
W HILE ON ADMINISTRATIVE
LEAVE , YOU WILL NOT BE ABLE TO EARN ACADEMIC CREDIT FOR ROTATIONS , CLERKSHIPS OR ELECTIVES .
T HIS ALSO
MAY IMPACT YOUR STUDENT PRIVILEGES , INCLUDING ELIGIBILITY FOR HOUSING AND LOAN DEFERMENT .
I agree to the terms above
I do not agree to the terms above
R EQUIREMENTS
W ILL YOU HAVE COMPLETED ALL NON ELECTIVE REQUIREMENTS FOR YOUR CLASS ?
Yes
No
If not, which requirements remain?
S IGNATURE
Student’s Signature: ________________________________ Date: ____________________________

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One Gustave L. Levy Place
Annenberg Building Room 13-30
Box 1257
New York, NY 10029-6574
Phone: (212) 241-6691
Facsimile: (212) 369-6013
E-mail: Registrar@mssm.edu
S CHOLARLY Y EAR S OURCE OF F UNDING F ORM
( FOR I NDEPENDENT S CHOLARLY Y EAR AND D EGREE P ROGRAMS O NLY )
F UNDING
Y OU ARE REQUIRED TO H AVE A SOURCE OF SUPPORT TO FINANCE COSTS ASSOCIATED WITH A S CHOLARLY Y EAR .
S
TUDENT LOANS ARE NOT AV AILABLE FOR THIS PURPOSE
.
W HILE ON S CHOLARLY Y EAR , YOU ARE EXPECTED TO WORK FULL TIME ON YOUR PROJECT .
Y OU ARE NOT PERMITTED
TO HAVE OTHER MAJOR COMMITMENTS OR RESPONSIBILITIES OR TO HOLD AN OUTSIDE JOB DURING NORMAL WORK
HOURS , E .
G .
9:00 AM TO 5:00 PM .
V IOLATION OF THESE TERMS MAY RESULT IN CONVERSION OF LEAVE TO AN
ADMINISTRATIVE LEAVE .
Source of Funding: __________________________________________________
(name of sponsoring agency or mentor)
Amount of Funding: _________________________________________________ (amount required for all students)
Mentor’s Name: Mentor’s Signature:
A GREEMENT
I UNDERSTAND THAT IF I BEGIN A S CHOLARLY Y EAR PROGRAM WITHOUT HAVING OBTAINED PRIOR WRITTEN
APPROV AL THAT MY STATUS CAN AUTOMATICALLY BE CONVERTED TO AN ADMINISTRATIVE LEAVE .
I HAVE READ , UNDERSTAND AND AGREE TO THE TERMS OF THIS S CHOLARLY Y EAR
Student’s Signature: ________________________________ Date: ____________________________
G UARANTOR
I F ANOTHER INDIVIDUAL ( PARENT , SPOUSE , ETC ) ASSUMES RESPONSIBILITIES FOR YOUR SUPPORT , S / HE MUST SIGN
THIS FORM AS WELL .
P LEASE HAVE THE GUARANTOR
’
S SIGNATURE NOTARIZED .
Guarantor Name (print): __________________________ Relationship to Student: _______________________
Guarantor Signature: _________________________________________________ Date: _________________