First Name of Person Submitting this Form** Applications must be submitted by someone within the department, not the prospective intern/shadow. **
* must provide value
Last Name of Person Submitting this Form* must provide value
University Job Title* must provide value
E-mail* must provide value
must be a University of Rochester e-mail address
First Name* must provide value
Last Name* must provide value
E-mail* must provide value
Phone Number* must provide value
Street Address* must provide value
City* must provide value
State/Province* must provide value
Country
Zip/Post Code* must provide value
Currently enrolled in the following academic program*:* must provide value
High School Diploma
Associate's
Bachelor's
Master's
PhD
MD
Other Doctoral
Certificate
Other
None
Academic Program - Other: Please specify:* must provide value
Field of Study* must provide value
Is this a UR student?* must provide value
Yes
No
Student's URID* must provide value
Current Educational Institution* must provide value
Current Educational Institution* must provide value
Is the applicant registered for academic credit related to this experience?* must provide value
Yes
No
Is the applicant 18 years or older?* must provide value
Yes
No
Emergency Contact Name* must provide value
Relationship* must provide value
Phone Number* must provide value
Alternate Phone Number
For interns and shadows under 18 years of age, the Parental Consent Form must be completely filled out, signed, and submitted with this online application form.Parental Consent Form Parental Consent Form* must provide value
For interns and shadows under 18 years of age, the Adult Supervisor's Training Compliance Form must be signed and submitted with this online application form.Supervisor Training Compliance Form Supervisor's Training Compliance Form* must provide value
The Department Administrator is responsible for completing the Background Check Process.Background Check Process Background Check Results* must provide value
Hosting Department* must provide value
Anesthesiology M&D Anethesiology Research Biochemistry and Biophysics Biomedical Engineering Biostats Computational Biology Cancer Center M&D Center for Community Health & Prevention Center for Health + Technology (CHeT) Center for Musculoskeletal Research Center for Neurotherapeutics Discovery Center for Oral Biology Center for Pediatric Biomedical Research Center for Translational Neuromedicine Center for Vaccine Biology and Immunology Clinical Ethics Dept of Biomedical Genetics Dermatology M&D Eastman Institute for Oral Health EHS Toxicology Trng Prog Emergency Medicine Environmental Medicine Fitness & Wellness Center General Neurology Unit Health Lab Imaging Sciences-Faculty Infectious Disease Life Sciences Learning Ctr (Env Med) Med M&D-Aab CardiovascResInst Med M&D-Pulmnry/Crit Care Unit Medicine M&D Endo-Metab Div Medicine M&D-Cardiol Hrt Res Medicine M&D-Cardiology Div Medicine M&D-Immuno/Rheum Div Medicine M&D-Nephrology Div Microbiology & Immunology M&D National Center for Deaf Health Research (NCDHR) Neuroscience Neurodev & Behav Pediatrics Neurology/Ctr Trans Neuromed Neurosurg/Ctr Trans Neuromed Neurosurgery OBGYN Research Ophthalmology M&D Orthopaedics M&D Otolaryngology Pathology & Lab Medicine M&D Pediatrics Allergy Pediatrics M&D Inf Diseases Pediatrics M&D Neonatology Pediatrics Med Ctr Pharmacology & Physiology Physical Medicine & Rehabilitation (PMR) Primary Care Psychiatry Psychiatry M&D Psychology Psychiatry M&D Research Public Health Sciences Grads Radiation Oncology M&D Surgery Research Thoracic Surgery M&D Urology M&D
Experience Advisor's First Name* must provide value
Experience Advisor's Last Name* must provide value
Experience Advisor's Email* must provide value
Department Administrator's First Name* must provide value
This person must be an Administrator
Department Administrator's Last Name* must provide value
This person must be an Administrator
Department Administrator's Email* must provide value
This person must be an Administrator
Would you like to include a Department Administrator Delegate as well? This would be used in cases when the Administrator has delegated responsibility for managing the internship/shadowing program to another individual in the department.* must provide value
Yes
No
Department Administrator Delegate's First Name* must provide value
Department Administrator Delegate's Last Name* must provide value
Department Administrator Delegate's Email* must provide value
Is this an internship or shadowing experience?* must provide value
Internship
Shadowing Experience
The intern must obtain a statement from their school which attests that s/he is a student whose course of instruction leads to a degree, diploma, or certificate. This statement must be on school letterhead and may be from the school's Registrar or from a professor at the school. The statement should include the current registration status and the expected degree completion date. The Hosting Department must submit the statement with this application.* must provide value
Internships may last no longer than 6 months and, if appropriate, may be renewed. In order to renew, a new application form and statement of enrollment will need to be submitted and approved.* must provide value
Yes
No
Shadowing experiences may last no longer than 160 total hours over the course of 6 months, and may not be renewed. This shadowing experience may last no longer than 160 total hours over the course of 6 months, and may not be renewed. Start Date* must provide value
M-D-Y
End Date* must provide value
M-D-Y 6 months max.
Total Hours* must provide value
160 hours max.
The Hosting Department is responsible for complying with all policies and training requirements in a timely manner. Compliance-related documentation should be retained at the departmental level. The Department must be able to produce all documentation within 24 hours for audit purposes. The Department may also have additional, department-specific, policy/training requirements. Will any part of this experience take place in a laboratory?* must provide value
Yes
No
The Environmental Health & Safety Guidelines for Visitors to Laboratories must be adhered to and any related lab safety training is required.EH&S Guidelines for Visitors to Labs Will the individual participate in an internally/externally sponsored research program?* must provide value
Yes
No
An Intellectual Property Agreement is required.Intellectual Property Agreement Intellectual Property Agreement - Supporting Information Will the individual have access to patient information?* must provide value
Yes
No
HIPAA Privacy and Security training and Mandatory In-Service training are required.HIPAA Privacy and Security Training MyPath: Request Account for the purpose of completing this requirement. Will the individual do any clinical shadowing as part of the experience?* must provide value
Yes
No
In addition to this approval process, compliance with Strong Memorial Hospital Policy 12.07 for clinical shadowing is required separately.PolicyStat : Strong Memorial Hospital Policy Manual (URMC Intranet) Search for "Short-Term Observational Experiences Policy" Will the intern have any hands-on patient contact?* must provide value
Yes
No
In addition to this approval process and compliance with Strong Memorial Hospital Policy 12.07, a Health Assessment via University Health Service is also required.Process to Arrange for Health Assessment through University Health Service Department Chair approval and an Affiliation Agreement (SMH Policy 12.05) are also required. SMD-Internship-Program will advise you on this.PolicyStat : Strong Memorial Hospital Policy Manual (URMC Intranet) Search for "Affiliations with Other Institutions for Educational Purposes Policy" It is required that the individual be supervised at all times either by the Advisor or an appropriate delegate. Supervisory Delegate #1
Supervisory Delegate #1
Supervisory Delegate #1
Supervisory Delegate #2
Supervisory Delegate #2
Supervisory Delegate #2
Supervisory Delegate #3
Supervisory Delegate #3
Supervisory Delegate #3
Supervisory Delegate #4
Supervisory Delegate #4
Supervisory Delegate #4
The renewal application must include new educational goals and nature of work. Indicate the educational goals of the experience. Please be specific.* must provide value
Describe the nature of the work that will be performed.* must provide value
At the end of the experience, interns must complete at least one final project. Indicate the type of final project that will be required.* must provide value
Oral report - presented to the lab group or to a wider audience
Poster - presented at a formal poster presentation of some kind
Written report - provided to the Advisor
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