US Graduates
Program Name: Preventive Medicine Residency
A University of Wisconsin Hospital and Clinics sponsored GME program
Application Deadline: Please contact the PMR program
Thank you for your interest in Graduate Medical Education at the University of Wisconsin Hospital and
Clinics. Here is checklist of items needed for your application to be considered complete. For students and
graduates of non-LCME accredited medical schools (IMGs) please see the reverse side.
UWHC Uniform Graduate Medical Education Application form for non-ERAS applicants (completely filled
out and signed. CVs will not be accepted in lieu of the Application). You must sign and date the attestation
form at the end of the application.
Current CV
Current and former Program Director(s) letter of recommendation (All former Program directors of a US
based program must be included)
If there are not at least 3 letters of recommendation from program directors, please submit additional
letters of recommendation to have a minimum of 3 total letters of recommendations.
USMLE scores or NBOME (COMLEX scores). If we can verify full medical licensure that required Step
III completion via the AMA profile, this requirement will be waived.
Medical School Transcript. If we can verify your graduation via the AMA profile, this requirement will be
waived.
Medical School Letter of Evaluation (formerly known as the Dean’s letter)..
Personal Statement. Please write a current one for this application.
Please return all materials to:
Kelly Coffey
Preventive Medicine Residency Program Coordinator
University of Wisconsin School of Medicine and Public Health
Health Sciences Learning Center Room# 4267
750 Highland Avenue
Madison, Wisconsin 53705
Page 1 of 12
International Medical Graduates
Program Name: Preventive Medicine Residency
A University of Wisconsin Hospital and Clinics sponsored GME program
Application Deadline: Please contact the PMR program
Thank you for your interest in Graduate Medical Education at the University of Wisconsin Hospital and
Clinics. Here is checklist of items needed for your application to be considered complete. (For students and
graduates of LCME accredited medical schools (US Graduates) please see the reverse page.
UWHC Uniform Graduate Medical Education Application form for non-ERAS applicants (completely
filled out and signed. CVs will not be accepted in lieu of the Application). You must sign and date the
attestation form at the end of the application.
If there are not at least 3 letters of recommendation from program directors, please submit additional
letters of recommendation to have a minimum of 3 total letters of recommendations.
ECFMG certificate (must be complete prior to start of training).
Current and former Program Director(s) letter of recommendation (All former Program directors of a US
based program must be included) IMG’s must have at least one letter from a program director certifying one
year of US clinical experience.
USMLE scores or NBOME (COMLEX scores) ECFMG is OK.
Medical School Transcript (from ECFMG)
Medical School Letter of Evaluation (if available, in English)
Personal Statement. Please write a current one for this application.
Please return all materials to:
Kelly Coffey
Preventive Medicine Residency Program Coordinator
University of Wisconsin School of Medicine and Public Health
Health Sciences Learning Center Room# 4267
750 Highland Avenue
Madison, Wisconsin 53705
Page 2 of 12
University of Wisconsin
Request for Letter of Recommendation
For Non-ERAS Application Process
Date:
Letter Writer:
Applicant Name:
Thank you for agreeing to write a letter of recommendation in support of my application. This sheet
explains the special procedures needed to prepare a letter for the University of Wisconsin Hospital
and Clinics residency programs.
Please send the letter of recommendation to the designated department using the following format.
1. Address the letter to “Dear Program Director or Department Chair”.
(I would be happy to provide you a list of programs to which I am applying). Include in
the letter that I have or have not waived my right to see this recommendation, as
indicated below.
2. Write your letter on letterhead.
3. Please print your letter to be placed in my file.
4. Attach this sheet to your letter before sending it, to help my designated department to
identify your letter with my file.
Thank you in supporting my application.
_____ (I waive) _______ (I do not waive) my right to see this letter. If “waived” is checked, I waive
my right to see this letter. I acknowledge that this letter is for the specific purpose of supporting my
application for an Internship, Residency or Fellowship.
SIGNED: _____________________________________________________
Mailing Address:
Name: __________________________________________________
Department: __________________________________________________
Address: __________________________________________________
City: __________________ ST: _____________ ZIP: ___________
Phone: __________________________________________________
Email: __________________________________________________
Page 3 of 12
UWHC Graduate Medical Education Application
(for non-ERAS applicants)
This worksheet may be used to begin completing your application electronically. All required fields are marked with an asterisk (*).
Please note, however, that some of these fields are required only in certain circumstances. For example, if you state that you did
earn or expect to receive a degree from an institution, you will be required to enter what that degree is.
Program you’re applying for:
Profile
First Name*:
Previous Last Name:
Degree:
MD
Current Address:
Street Address: *
City: *
Preferred Phone: *
Pager:
Program Start Date
Middle Name:
MD, PhD
Last Name: *
DO
State/Province: *
Alternate Phone: *
Fax:
Permanent Mailing Address:
Street Address: *
City : *
State/Province: *
Country: *
Phone: *
NPI Number
Anticipated Training Year:
MBBS
Post Code: *
Mobile:
Contact Email:
Suffix:
MBchS
Country: *
Post Code: *
Canadian SIN:
Match Participation:
I am applying for position outside the match.
I am participating in the NRMP Main Match.
I am participating in the NRMP Specialties Match.
I am participating in a match as part of a couple AND I wish to notify programs of this.
San Francisco Matching Service
AUA Number:
(required for Urology Match Participants only)
Other
Specialties Partner is applying to:
Partner’s Name:
Military
Are you committed to fulfill U.S. Military active duty service obligations/deferments? *
Yes
No
If Yes: Years:
Branch:
Do you have any other service obligations? (i.e., Military Reserves or Public Health/State programs) *
Yes
No
Description (up to 255 characters)
Page 4 of 12
Work Eligibility
Do you meet one of the following criteria?
Yes
No
1. US citizenship
2. Permanent legal residency status in the US (green card)
3. Eligible to hold a J-1 Clinical Visa sponsored by ECFMG.
Note: The UWHC will not sponsor H-1 (temporary worker) visas. Other legal documents authorizing work In the
United States will be reviewed by the GME office.
Foreign Medical Graduates:
Are you certified by the Educational Commission for Foreign Medical Graduates?
(Attach a copy of the ECFMG certificate). Check all that apply.
No
Yes
Month:
Year:
USMLE/ECFMG ID:
ECFMG certificate is attached with the application. *
Miscellaneous
Foreign Medical Graduates applying for Residency Positions: To be answered by Foreign Medical Graduates only. See
www.ecfmg.org/eras for information and mailing instructions.
Will you provide a MSPE to the UWHC? *
Yes
No
Will you or your medical school provide a transcript to UWHC? *
**Please attach copies and a translation if not in English
Yes
No
Non-Medical Education
For each non-medical educational institution you have attended, please provide the requested information. You may create as
many entries as needed on an additional page.
None
#1
Institution: *
Location: *
Education Type: * (--------) Major:
Degree expected or earned: *
Degree:
Degree Month:
Degree Year:
Dates of Attendance*: From:
To:
Month/year
Month/year
#2
Institution: *
Location: *
Education Type: * (--------) Major:
Degree expected or earned: *
Degree:
Degree Month:
Degree Year:
Dates of Attendance*: From:
To:
Month/year
Month/year
Yes
No
Yes
No
Refer to attachment for additional information. (Reference as 2-a, 2-b)
Medical Education
For each medical school you have attended, please provide the requested information. You may create as many entries as needed
on an additional page.
#1
Country:
Institution: *
Clinical Campus:
* only available for select US Medical Schools
Degree expected or earned: *
Yes
No
Degree:
Degree Month:
Degree Year:
Dates of Attendance*:
From:
To:
Month/year
Month/year
Page 5 of 12
#2
Country:
Institution: *
Clinical Campus:
* only available for select US Medical Schools
Degree expected or earned: *
Yes
No
Degree:
Degree Month:
Degree Year:
Dates of Attendance*:
From:
To:
Month/year
Month/year
Refer to attachment for additional information. (Reference as 3-a)
Previous Training
For each internship, residency, or fellowship position you have held or currently are in, regardless of the amount of time spent there,
please provide the requested information. This worksheet has space for you to make 3 entries. You may create as many entries as
needed on an additional page.
None
#1
Specialty:*
Type of Training:*
Internship
Dates of Residency/Fellowship:
Institution/Program:*
City:*
State/Province:*
Program Director:*
Residency
From:
Month/year
Fellowship
To:
Month/year
Country:*
Supervisor:*
Years:
#2
Specialty: *
Type of Training: *
Internship
Residency
Fellowship
Dates of Residency/Fellowship:
From:
To:
Month/year
Month/year
Institution/Program: *
City: *
State/Province: *
Country: *
Program Director: *
Supervisor: *
#3
Specialty: *
Type of Training: *
Internship
Residency
Fellowship
Dates of Residency/Fellowship:
From:
To:
Month/year
Month/year
Institution/Program: *
City: *
State/Province: *
Country: *
Program Director: *
Supervisor: *
Years:
Years:
Chief Resident (only available for Fellowship Applicants)
Dates of Residency/Fellowship:
From:
To:
Month/year
Month/year
Reason for leaving (up to 510 characters)
Was your medical education/training extended or interrupted? Please explain any gaps of 3 or more months during your medical
education and / or residency training? *
No
No Response
Yes - Reason (up to 510 characters)
Refer to attachment for additional information. (Reference as 3-b)
Page 6 of 12
State Licenses
For each state license you have, please provide the requested information. This worksheet has space for you to make 2 entries.
You may create as many entries as needed on an additional page.
None
#1
State*
License Type *
Full
Temporary or Limited
Inactive
License Number*
Expiration Month*
Expiration Year*
(License number, expiration month, and expiration year is only required if license type is “Full”)
#2
State*
License Type *
Full
Temporary or Limited
Inactive
License Number*
Expiration Month*
Expiration Year*
(License number, expiration month and expiration year is only required if license type is “Full”)
Refer to attachment for additional information. (Reference as 4-a)
Medical Licensure
Has your Medical License ever been suspended/revoked/voluntarily terminated? *
No
Yes Reason (up to 510 characters)
Have you ever been named in a malpractice case? *
No
Yes - Reason (up to 510 characters)
Malpractice Claims History is attached (Reference as 4-b)
Is there anything in your past history that would limit your ability to be licensed or to receive hospital privileges? *
No
Yes - Reason (up to 510 characters)
Have you ever been convicted of a felony? *
No
Yes Reason (up to 510 characters)
Are you Board Certified?
No
Yes Board Name
1.
Expiration
2.
3.
DEA #
Registration Number
Expiration Month
if applicable
Expiration Year:
Page 7 of 12
Examinations
For each examination you have taken, please provide the requested information. This worksheet has space for you to make 4
entries. (Osteopathic applicants: include the exams (COMLEX or USMLE) that lead to the medical licensure route you intend to
pursue).
None
Exam #1:
1st attempt
2nd attempt
Title: ( ------------)
Status: ( -----------)
(Month/Year)
Exam #2:
1st attempt
2nd attempt
Title: ( ------------)
Status: ( -----------)
(Month/Year)
Exam #3:
1st attempt
2nd attempt
Title: ( ------------)
Status: ( -----------)
(Month/Year)
Exam #4:
1st attempt
2nd attempt
Title: ( ------------)
Status: ( -----------)
(Month/Year)
Cardiopulmonary Resuscitation & Other Life Saving Intervention Certification
I am CPR/BLS (Cardiopulmonary Resuscitation) certified in the U.S.A
Expiration Date:
I am ACLS (Advanced Cardiac Life Support) certified in the U.S.A.
Expiration Date:
I am PALS (Pediatric Advanced Life Support) certified in the U.S.A.
Expiration Date:
I am ATLS (Advanced Trauma Life Support) certified in the U.S.A.
Expiration Date:
Month/year
Month/year
Month/year
Month/year
Experience(s)
For each non-residency relevant work, research, and volunteer experience/position you have had, please provide the requested
information. Include non-residency clinical and teaching experience as work experiences, and include all unpaid extra-curricular
activities and committees you have served on as volunteer experiences. This worksheet has space for you to make 2 entries. You
may create as many entries as needed on an additional page.
None
#1
Type:
Work
Research
Volunteer
Organization: *
Position: *
Supervisor: *
Average Hours Per Week: *
Dates of Experience: *
From:
(Month/Year)
Description (up to 1020 characters)
Reason for leaving (up to 510 characters)
#2
Type:
Work
Research
Volunteer
Organization: *
Position: *
Supervisor: *
Average Hours Per Week: *
Dates of Experience: *
From:
(Month/Year)
To:
(Month/Year)
To:
(Month/Year)
Description (up to 1020 characters)
Reason for leaving (up to 510 characters)
Description (up to 1020 characters)
Reason for leaving (up to 510 characters)
Refer to attachment for additional information. (Reference as 5-a)
Page 8 of 12
Publications
(Use also for Poster Sessions/Abstracts/Invited National or Regional Presentations)
For each publication/presentation you have had, please provide the requested information. This worksheet has space for you to
make 6 entries.
None
#1
Title: *
Authors/Presenters: *
Publication/Organization: *
Month:
Year:
Volume:
Pages:
#2
Title: *
Authors/Presenters: *
Publication/Organization: *
Month:
Year:
Volume:
Pages:
#3
Title: *
Authors/Presenters: *
Publication/Organization: *
Month:
Year:
Volume:
Pages:
#4
Title: *
Authors/Presenters: *
Publication/Organization: *
Month:
Year:
Volume:
Pages:
Refer to attachment for additional publications. (Reference 6-a)
All applicants:
Language Fluency (Other than English): (255 characters)
Hobbies and Interests: (510 characters)
Medical School Awards: (510 characters)
Other Awards/Accomplishments: (510 characters)
Membership in Honorary/Professional Societies: (255 characters)
Are you able to carry out the responsibilities of a resident in the specialties and at the specific training programs to which you are
applying including the functional requirements, cognitive requirements, interpersonal and communication requirements, and
attendance requirements with or without reasonable accommodations? *
Yes
No Response
No – Pleased describe limiting aspects on Appendix A.
Page 9 of 12
Appendix A:
Visa, Conviction, and Accommodations
This sheet will be removed before decision makers decide who to interview. Information below may be
discussed during the interview. Information on this page is necessary only after the applicant has been
offered an interview.
Applicant Name:
Program Name:
Felony Question
Have you ever been convicted of a felony?
Yes
Have you ever been convicted of a misdemeanor?
No
Yes
No
** Section 111.321, Wis. Stats., generally prohibits employment discrimination on the basis of arrest or conviction
record. An employer may only refuse to hire a qualified applicant because of a conviction record for an offense that is
substantially related to the circumstances of a particular job. The legislature has determined that certain convictions
are substantially related to employment in child and adult care giving programs regulated by the Department of Health
and Family Services.
Work Eligibility: *
(-----------)
Current and Expected Visa Types: (for Foreign Nationals only - check all that apply)
B-1 - Temporary visitor for business
B-2 - Temporary visitor for pleasure
F-1 - Academic student business, or athletics
F-2 - Spouse or child of F-1
TN - NAFTA trade visa for Canadians and Mexicans
H-1 - Temporary worker
TN - NAFTA trade visa for Canadians and Mexicans
H-1B - Specialty occupation, DoD worker, etc.
Diplomatic Service
H-2B - Temporary worker- skilled and unskilled
Immigrant
H-4 - Spouse or child of H-1, H-2, H-3
EAD-Employment Authorization
J-1 - Visa for exchange visitor
J-2 - Spouse or child of J-1
O-1 - Extraordinary ability in sciences, arts, education,
Other
**University Hospital and Clinics only sponsors J1 training Visa’s for residents and fellows.
Expected Visa Type (for training)
J1
EAD
Other ______________________
Are you able to carry out the responsibilities of a resident in the specialties and at the specific training programs to
which you are applying including the functional requirements, cognitive requirements, interpersonal and
communication requirements, and attendance requirements with or without reasonable accommodations? *
No – Pleased describe limiting aspects.
Page 10 of 12
Personal / Demographic Information
Appendix B:
**This information will not be available to decision-makers prior to a position being offered
through a match or non-match process.
Applicant Name:
Program Name:
Social Security Number: * SSN:
Marital Status:
Gender:
Married
Female
Birth Birth Date: *
Birth State:
Single
Male
Birth City:
Birth Country
Racial and Ethnic Group:
This section allows entries for race self-identification. You may select one or more races. You are not
required to identify your race. If you choose not to, please select "No Answer." Specify "other" if your race
is not listed. You may create as many entries as needed.
Black (not of Hispanic Origin): All persons having origins from any of the black racial groups.
Asian or Pacific Islanders: All persons having origins from any of the original peoples of the Far East,
Southeast Asia, the Indian subcontinent or the Pacific Islands. This area includes, for example, China,
Japan, Korea, the Philippine Islands, Samoa, and India.
American Indian or Alaskan Native: All persons having origins of the original peoples of North
America, and who maintain cultural identification through tribal affiliation or community recognition.
Hispanic: All persons from Mexican, Puerto Rican, Cuban, Central or South American, Iberian
Peninsula, or other Spanish culture or Origin, regardless of race.
White (not of Hispanic Origin): All persons having origins from any of the original peoples of Europe,
North Africa, and the Middle East.
Unknown
Other: _________________________________________________
Page 11 of 12
Attestation
Background Disclosure and Check. I understand that I must fill out a Wisconsin Background Information
Disclosure (BID) form and that a background check will be performed as required by state law. The BID
form is considered part of this application. I understand that I will not be employed or will be removed from
employment if the employer discovers certain crimes or offenses. If I am assigned to work at another site
that requires a BID form and check, I authorize UWHC to release this information to the other site.
Health Screening and Drug Testing. I understand that any offer of employment is contingent on
successful completion of a pre-employment physical which will include mandatory pre-employment drug
testing and which also may include alcohol testing. I understand the UWHC will rescind my offer of
employment if I do not comply with all procedures for pre-employment drug testing. I understand that I
should consider whether I wish to provide notice of my intent to end my employment with my current
employer prior to successfully passing the UWHC’s pre-employment drug testing.
Identity and Work Authorization: Federal law requires UWHC to verify the identity and work authorization
of each successful candidate. Any offer of employment is contingent upon this verification.
Social Security Number: I understand that UWHC will use the Social Security Administration’s Verification
Service (EVS) to verify my social security number after hire, if I am hired.
Authorization of Release of Information. I authorize the release of information to UWHC regarding my
work history, education, licensing/certification, performance, and malpractice claims history. I understand
that any offer of employment is contingent upon UWHC obtaining satisfactory responses to inquiries. I
hereby release all persons or entities from all actions, causes of action, liability, claims, demands, either
criminal or civil, damages and costs arising from, or in connection with the reviewing or the furnishing of
information to said Hospital or the members of the Graduate Medical Education office or residency program
staff to facilitate the assessment of my qualifications for appointment to its GME training programs.
Certification of Accuracy and Completeness. I certify that all of the information provided in this
application is true and complete to the best of my knowledge. I acknowledge that I may be required to verify
information prior to appointment and that any omitted, false or misleading information may disqualify me
from employment consideration and may be grounds for termination from employment.
Signed:_____________________________________ Date:_______________
Printed Name:_____________________
Please print off this page. Sign, date, and scan to program applying for.
Page 12 of 12