Request Rotation Form Type of StudentPlease Choose…Medical StudentPA StudentNP StudentDesired RotationChoose a Rotation…Emergency MedicineFamily MedicineInternal MedicineGeneral SurgeryOB/GynOrthopedicsUrologyDesired RotationChoose a Rotation…Internal MedicinePediatricsName First Last School Email PhoneSelect up to 3 dates1st Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 2nd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 3rd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 1st Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 Block 7: 12/16/24 – 01/12/25 2nd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 Block 7: 12/16/24 – 01/12/25 3rd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 Block 7: 12/16/24 – 01/12/25 1st Choice Block 1: 07/01/24 – 07/28/24 Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 2nd Choice Block 1: 07/01/24 – 07/28/24 Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 3rd Choice Block 1: 07/01/24 – 07/28/24 Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 1st Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 2nd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 3rd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 1st Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 2nd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 3rd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Block 6: 11/18/24 – 12/15/24 1st Choice Block 1: 07/01/24 – 07/28/24 Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 2nd Choice Block 1: 07/01/24 – 07/28/24 Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 3rd Choice Block 1: 07/01/24 – 07/28/24 Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 1st Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 2nd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 3rd Choice Block 2: 07/29/24 – 08/25/24 Block 3: 08/26/24 – 09/22/24 Block 4: 09/23/24 – 10/20/24 Block 5: 10/21/24 – 11/17/24 Anticipated graduation MM slash DD slash YYYY Pass COMLEX/Step? Yes No Please explainPlease provide a brief statement regarding your background that led to an interest in Emergency Medicine.Please provide a brief statement regarding your background that led to an interest in Family Medicine.Please provide a brief statement regarding your background that led to an interest in General Surgery.Please provide a brief statement regarding your background that led to an interest in Internal Medicine.Please provide a brief statement regarding your background that led to an interest in in Obstetrics and Gynecology.Please provide a brief statement regarding your background that led to an interest in in Orthopaedic Surgery.Please provide a brief statement regarding your background that led to an interest in in Urology.Do you have experience in Emergency Medicine or related field?Why are you interested in University of Michigan Health-West?Work AuthorizationAre you currently authorized to work in the United States?(Required) Yes No What is your current work authorization?(Required) Will you need visa sponsorship through ECFMG (J-1) or the teaching hospital (H-1B) to complete the entirety of your GME training? Yes No Our program is an Osteopathic Recognized (OR) Family Medicine Residency Program and all of our residency slots are currently designated as such. If you are a graduate of a Non-Osteopathic Medical School, please review the below qualifications that are required to enter our program: · Proof of evidence of training in osteopathic philosophy, history, terminology, and code of ethics. · Proof of evidence of training in anatomy and physiology related to osteopathic medicine. · Proof of evidence of training on indications, contraindications, and safety issues associated with the use of osteopathic manipulative treatment. · Proof of evidence of training in palpatory diagnosis, osteopathic structural examination, and osteopathic manipulative treatment. If you have had experiences in Osteopathic Principals and Practice (OPP) which you believe fulfill these requirements, please attach below. If you have not had the required experiences but are still interested in training in an OR program, please attach a brief explanation as to why you are interested in our program along with an outline explaining how you plan to meet the OPP requirements. Please note that we typically conduct interviews during the months of November, December and January.What are your hobbies?Please upload any information you feel would be helpful to the program in making a decision. (test scores, transcript, etc.)Max. file size: 712 MB.Please upload the following: CV, Transcript, General Surgery and Internal Medicine COMAT or Shelf Exam scoresMax. file size: 712 MB.Consent I understand that UMH-West offers visiting medical students one rotation in one specialty per academic year.Please proofread the spelling of your name, phone number and email address before submitting this request. It may take up to ten business days to review and process your application (unless you receive an out of office notice, in that event it will begin on their return).PhoneThis field is for validation purposes and should be left unchanged. Δ