SMD Unpaid Academic Internship and Shadowing Program Application Form

Last Name of Person Submitting this Form

University Job Title

E-mail

First Name

Last Name

E-mail

Phone Number

Street Address

City

State/Province

Country

Zip/Post Code

Currently enrolled in the following academic program*:

*Medical (MD) students may only participate in this program if the experience is research-only with no clinical component. Clinical experiences must be organized through OME.

Academic Program - Other: Please specify:

Field of Study

Is this a UR student?

Student's URID

Current Educational Institution

Current Educational Institution

Is the applicant registered for academic credit related to this experience?

Is the applicant 18 years or older?

Emergency Contact Name

Relationship

Phone Number

Alternate Phone Number

Parental Consent Form

Supervisor's Training Compliance Form

Background Check Results

Please upload a copy of the email from Human Resources confirming all adult supervisors have been cleared.

Hosting Department

Experience Advisor's First Name

Advisor may not be a student.

Experience Advisor's Last Name

Advisor may not be a student.

Experience Advisor's Email

Advisor may not be a student.

Department Administrator's First Name

Department Administrator's Last Name

Department Administrator's Email

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.

Department Administrator Delegate's First Name

Department Administrator Delegate's Last Name

Department Administrator Delegate's Email

Is this an internship or shadowing experience?

An internship is appropriate if there is to be a legitimate learning experience that will benefit the student as an extension of his/her academic experience. An internship offers the student an opportunity for active and engaged training under constant supervision.

A lab/research shadowing experience is appropriate if the individual will be doing no work, will be constantly supervised, and will simply be observing his/her supervisor. Shadows may only perform minimal mirroring of experiments, techniques, etc. Shadows may not have any hands-on patient/human research subject contact. Strict adherence to these guidelines is necessary to avoid the potential that a shadowing opportunity could be considered a volunteer or intern arrangement, both of which would be prohibited under existing New York State Department of Labor guidelines. A shadowing experience is not appropriate in cases where a supervisor wishes to evaluate an individual for a future paid position for the same reason.

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.

Graduating high school seniors must obtain a statement from their post-secondary institution. A copy of the receipt/confirmation of deposit is acceptable. Undergraduate, graduate, and other students who are transitioning between degree programs must provide a statement from both their current and future institutions.

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.

Is this an application to renew an internship?

The supervisor acknowledges that the shadowing experience is entirely for the benefit of the individual and that the supervisor may not request or require the individual to perform any work, volunteer, or other tasks related to the department's work.

Start Date

End Date

Total Hours

Is this experience being conducted remotely/online-only?

Will any part of this experience take place in a laboratory?

Will the individual have access to patient/human research subject information?

Will the individual do any clinical shadowing as part of the experience?

Will the intern have any hands-on patient/human research subject contact?

Supervisory Delegate #1
First Name

Supervisory Delegate #1
Last Name

Supervisory Delegate #1
Official University Title

Supervisory Delegate #2
First Name

Supervisory Delegate #2
Last Name

Supervisory Delegate #2
Official University Title

Supervisory Delegate #3
First Name

Supervisory Delegate #3
Last Name

Supervisory Delegate #3
Official University Title

Supervisory Delegate #4
First Name

Supervisory Delegate #4
Last Name

Supervisory Delegate #4
Official University Title

Indicate the educational goals of the experience. Please be specific.

Describe the nature of the work that will be performed, in detail.

At the end of the experience, interns must complete at least one final project. Indicate the type of final project that will be required.