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SMD Unpaid Academic Internship and Shadowing Program Application Form

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Please complete* this form electronically. Scanned and/or printed forms will not be accepted. You are allowed to leave the survey and return later.

*It is the Hosting Department's responsibility to complete this form. Prospective interns/shadows are not to complete the form under any circumstances. Applications submitted by prospective interns/shadows will not be accepted.

Internships and shadowing experiences are not organized by this Program. Individuals should visit URMC's Departments & Centers listing to determine where they would like to seek an internship/shadowing experience, then contact that department to inquire about an opportunity.

Check the Program Selection Grid for URMC Educational Experiences to determine whether this is the correct program for the interested party. Email SMD-Internship-Program@urmc.rochester.edu for more information.

Refer to the Program Requirements and FAQs as needed.

Thank you!

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

First Name

* must provide value

Last Name

* must provide value

E-mail

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Phone Number

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Street Address

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City

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State/Province

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Country

Zip/Post Code

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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.

* must provide value

High School Diploma

Associate's

Bachelor's

Master's

PhD

Other Doctoral

Certificate

Other

None

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Academic Program - Other: Please specify:

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Field of Study

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Is this a UR student?

* must provide value

Yes

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Student's URID

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Current Educational Institution

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Current Educational Institution

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

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Yes

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Is the applicant 18 years or older?

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Yes

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Emergency Contact Name

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Relationship

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Phone Number

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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

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For interns and shadows under 18 years of age, the Obligations of Adult Supervisors of Interns Under 18 Training Compliance Form must be submitted in conjunction with this online application form and the Parental Consent Form.

Adult supervisors include the intern/shadow's Advisor(s) and any delegates that may supervise the intern/shadow.

All adult supervisors of interns and shadows under 18 are required to complete training by completing the course, Programs for Minors and Children: Minimal Standards via MyPath.

Supervisor Training Compliance Form

Supervisor's Training Compliance Form

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Upload file

The Department Administrator is responsible for completing the Background Check Process.

This application will not be reviewed until proof of required Background Checks has been received. Interns/shadows under 18 may not start until all requirements are completed.

Adult supervisors include the intern/shadow's Advisor(s) and any delegates that may supervise the intern/shadow.

Background Check Process

Background Check Results

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

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Hosting Department

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Experience Advisor's First Name

Advisor may not be a student.

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Experience Advisor's Last Name

Advisor may not be a student.

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Experience Advisor's Email

Advisor may not be a student.

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Department Administrator's First Name

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Department Administrator's Last Name

* must provide value

Department Administrator's Email

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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.

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Yes

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Department Administrator Delegate's First Name

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Department Administrator Delegate's Last Name

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Department Administrator Delegate's Email

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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.

* must provide value

Internship

Shadowing Experience

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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.

* must provide value

Upload file

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?

* must provide value

Yes

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A lab/research shadowing experience requires that 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.

Shadowing experiences may last no longer than 160 total hours over the course of 6 months, and may not be renewed.

A lab/research shadowing experience requires that 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.

This shadowing experience may last no longer than 160 total hours over the course of 6 months, and may not be renewed.

Start Date

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M-D-Y

End Date

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M-D-Y

Total Hours

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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.

An Intellectual Property Agreement is required for all internships and shadowing experiences.

Intellectual Property Agreement

Intellectual Property Agreement - Supporting Information

Is this experience being conducted remotely/online-only?

* must provide value

Yes

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

* must provide value

Yes

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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

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

* must provide value

Yes

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HIPAA Privacy and Security training and Mandatory In-Service training are required.

HIPAA Privacy and Security Training

Mandatory In-Service Training:
Mandatory In-Service Training is available in MyPath for all employees. If someone does not have a MyPath account, the applicant or host department may request an account via MyPathSupport@Rochester.edu for the purpose of completing this requirement.

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

* must provide value

Yes

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Any clinical component of this experience such as clinical shadowing, clinical observership, clinical internship, etc. is not approved through our office.

In addition to this approval process, compliance with Strong Memorial Hospital Policy 12.07 for clinical shadowing is required separately.

Please note: Clinical shadowing experiences with no research component are not appropriate for our program and application process. Departments should instead pursue the process noted in SMH Policy 12.07.

SMH Policy 12.07 Short-Term Observational Experiences Policy (URMC Intranet)

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

* must provide value

Yes

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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. Please review SMH Policy 12.05: Affiliations with Other Institutions for Educational Purposes Policy (URMC Intranet) for further direction.

Important things to note:

The department is responsible for maintaining the affiliation agreement. In the event of an audit, the department needs to be able to produce the original.

The student cannot have any patient contact until all requirements are in place (Policy 12.07, health assessment, and the affiliation agreement).

It is required that the individual be supervised at all times either by the Advisor or an appropriate delegate.

Please list all such delegates below. The Advisor noted earlier in this application should not be listed again.

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

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

Expand

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

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Expand

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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