Rotations Shadowing and Research Application Form

Please upload the following documents below — pdf or doc file preferred

ACLS/BLS certification
BNDD
CV
DEA License (if permanent license holder)
ECFMG Certificate (if an international medical graduate)
MO License
Proof of malpractice coverage from your home institution
Visitor/Observer Packet
- For a rotation 7 days or less, please complete this packet: https://wustl.app.box.com/s/z1kt751znmzrivojzpxhxnmcberlmr0d.
- For a rotation of 8 or more days, please complete this packet: https://wustl.app.box.com/s/ovzyb6pqe0vpesk0pahghn57nmxv1r5a.

Please include your Last name-First name-file type (e.g., Last-First-ACLS.pdf)

Rotations, Shadowing, and Research Applications

Name

First

Last

Home Institution and State (Disclaimer: If a trainee requests a hands on rotation, they will be required to obtain a Missouri Medical License. Missouri Medical Licensure can take minimum of 120 days to obtain.)

Please list contact information for sponsoring institution Program Director and Coordinator(please include name, title, and email)

Position Position

PGY Level (must be PGY 2 or higher to be eligible)

Work Authorization

US Citizen or National, Legal Permanent Resident, Refugee, Asylee

Green Card Holder

Visa Holder, Please Enter Visa TypeVisa Holder, Please Enter Visa Type

OtherOther

Phone

What type of rotation are you interested in:

General GI Rotation (Hands-on clinical)

Shadowing (Hands-off observer)

Research

OtherOther

Rotation dates requested (Please be advised that the hospital does not allow outside rotators to start rotations from March-August. Please allow 16 weeks for application processing and approval. Drug screening must be completed in the United States, and can take up to 5 business days to process. Drug testing must be completed and approved by our non-appointee office before rotations & observerships can begin.)

Please list the faculty member with whom you would like to work:

Please describe why you are interested in visiting Washington University:

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