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Sample ERAS CAF - How to fill my form?
Here is a sample application form filled in with most of the details. If you are applying this might serve you as a starting point. Please use this as a guide only. The answers on this application might not suit your circumstances, please do your own research before filling in your application.
Here is the sample:
General Information
Name:
*************
Applicant ID:
***********
Previous Last Name:
AAMC ID:
********
Preferred Name: M
School:
#####
AOA ID:
E-mail
*********
AOA MATCH ID:
Gender:
****
AUA ID:
Birth Date:
**********
NRMP:
Yes
Birth Place:
*******
SSN:
SIN:
Citizenship:
Foreign National
Visa Type:
B-1 - Temporary visitor for business
USMLE ID:
0-888-888-0
Expected Visa Type(s):
NBOME ID:
H-1B - Specialty occupation, DoD worker, etcetera
J-1 - Visa for exchange visitor
Race:
Asian (Asian Indian)
Ethnicity:
Not Spanish/Hispanic/Latino/Latina
Present Mailing Address:
Permanent Mailing Address:
******, USA
******, Home country
Preferred Phone #: USA number
Phone #: home country
Alternate Phone #: home country
Mobile Phone #: USA number
Pager #:
Fax #:
Military Service Obligation/Deferment?
No
Other Service Obligation?
No
Felony Conviction?
No
Limitations?
No
Examinations
Examination
Status
Date
USMLE Step 2 CS (Clinical Skills)
Awaiting Result (this part cannot be changed after submission unlike ECFMG cert, see later)
08/2007
USMLE Step 2 CK (Clinical Knowledge)
Passed
date
USMLE Step 1
Passed
date
Medical Licensure
ACLS:
PALS:
DEA Reg. #:
Board Certification:
Yes
Name:
State medical council registration in home country
Medical Licensure Problem:
No
Ever named in a Malpractice Suit?
No
Past History?
No
State Medical Licenses
| Type | Number | State | Exp. Date |
| None |
Education Commission for Foreign Medical Graduate Certification
|
Medical Education
| Institution & Location | Dates Attended | Degree | Date of Degree | |
| **** | 888888 | Yes, MD | 88888 | |
| #### | 88888 | Yes, MBBS | 88888 | |
| Medical Education/Training Extended or Interrupted? | No | |||
Medical School Honors/Awards
| 1.Recipient of Gold medal for having secured the highest marks in Medicine in the MBBS 2.etc 3.etc 4.etc…there is word limit here so choose carefully |
Membership in Honorary/Professional Societies
|
Education
| None - unless you have premed education/degree in your country or have done some science related graduation before medical school. |
Current/Prior Training—Includes degrees, diplomas etc you have got after medical school
| Institution & Location | Program Director | Program Supervisor | Dates Attended | Years | Discipline |
| ***** | Name of guide | Name of guide | 88888 | 3 | Pediatrics |
| Reason for Leaving: | |||||
| Completion of 3 years residency program | |||||
Experience —WORK includes everwhere you worked and got paid. So for people who have the 5 and half year system with rotating internship (which is paid) write that here.
When you don’t get paid and you do clinical work its voluntary; for research all research which you did in med school or residency repeat there, irrespective of whether you got paid or not.
| Experience | Organization & Location | Position | Dates | Supervisor | Average Hours/Week | |
| Work | ABC | Senior Resident (Pediatrics) | 8888 | Named HOD | 50(take a logical guess, which would be supported by people at the institute if verified) | |
| Description | ||||||
| Senior Residency included working up patients, performing required procedures and managing critically ill newborns and children. During this period had regular night on-call duties which required attending to emergency and referral calls and managing cases unsupervised. | ||||||
| Reason for Leaving: | ||||||
| Change of residence to different state. | ||||||
| Work | ***** | Post Graduate Resident (Pediatrics) | 88888 | 50 | ||
| Description | ||||||
| 3 year Residency program; duties included teaching under graduate students of *** Medical College and planning their teaching schedules. Clinical Experience included first contact with patients, working up cases, performing all required diagnostic and therapeutic procedures (including exchange transfusions, intubations, central and arterial line placements, peritoneal dialysis catheter placement, venesections etc) and guided management & follow up. | ||||||
| Reason for Leaving: | ||||||
| Completion of 3 years residency program. | ||||||
| Work | ### Medical College, state, country | House Staff (Radiology) | 88888 | 40 | ||
| Description | ||||||
| Responsibility included interpretation and reporting of X- rays; conducting supervised ultrasonography. | ||||||
| Reason for Leaving: | ||||||
| Cleared Post graduate entrance exam in Pediatrics and left to join the same. | ||||||
| Work | ### Medical College, state, country | Intern (Obstetrics & Gynecology) | 88888 | 60 | ||
| Description | ||||||
| 8 week rotation wherein duties included patient evaluation in clinics and presenting same to consultants; obtaining the history and physical examination data for admitted patients; presenting admitted cases for morning rounds; supervised and independent management of obstetric cases including conducting deliveries of uncomplicated normal vaginal deliveries; assisting in operations; post operation follow up; antenatal clinic counseling and evaluation and completing notes and making discharges. | ||||||
| Reason for Leaving: | ||||||
| Completion of scheduled time during rotation. | ||||||
| Work | ### Medical College, state, country | Intern (Forensic Medicine) | 8888 | 40 | ||
| Description | ||||||
| Included 1 week period of going through cases presented to the department; observing autopsy procedures and completing documentation of cases. | ||||||
| Reason for Leaving: | ||||||
| Completion of scheduled period on rotation. | ||||||
| Work | ### Medical College, state, country | Intern (Preventive & Social Medicine) | 88888 | 60 | ||
| Description | ||||||
| 13 week rotation. Required going to underserved areas (ABC District) to learn about health care system there, the practical application of rural services, enhance public health education; conducted school health programs including check up of children, education regarding healthy lifestyle, referral and follow up in case of any diagnosed problem. Participated in the national immunization campaigns especially pulse polio initiative. Volunteered for the ongoing flood relief operation which included going to the stricken areas, setting up hygienic waste disposal system, educating people about the possible health issues in such a scenario, doing regular check up and distributing prophylactic and therapeutic medications and vaccinations. Participated in efforts to increase public health awareness by helping in the organization of health camps, lecture, poster making etc. | ||||||
| Reason for Leaving: | ||||||
| Completion of scheduled period of rotation. I included each of my internship rotations and described them. I know it sounds like unnecessary self praise to many IMGs especially from countries where rotating internship is mandatory, but firstly this year is equivalent to the experience AMGs get in transitional year which is valued highly in US and all my seniors wrote it this way, so I did it too. |
||||||
| Volunteer | Childrens' Hospital And Research Center city, state, USA | Observer (Pediatrics) | 888888 | 50 | ||
| Description | ||||||
| Observership for two months which is scheduled to include 1 month of General Pediatric rotation and 2 weeks each of Pediatric and Neonatal Intensive Care | ||||||
| Reason for Leaving: | ||||||
| Observership is scheduled to begin on Oct 1, 2007 and complete on Nov 30, 2007(observership hadn’t started when I submitted my application). | ||||||
| Volunteer | @@@, city, state, USA | Observer (Pediatrics) | 8888 | 50 | ||
| Description | ||||||
| Observership for 8 weeks with rotation of 2 weeks each in Pediatric Intensive Care, Pediatric Cardiology(specifically Intensive and Interventional), Neonatal Intensive care and 1 week each in Pediatric Neurology and Pediatric Emergency Department. Scheduled duties included evaluating patients during pre rounds and participating in discussions regarding further investigations and treatment; attending daily morning rounds, radiology rounds and weekly grand rounds; supervised evaluation of patients in clinics and their presentation; obtaining history & completing physical examination on newly admitted patients followed by presenting the cases to the in-charge resident/fellow/attending; observing the procedures that are conducted; and observing guardian counseling | ||||||
| Reason for Leaving: | ||||||
| Observership began on July 23, 2007 and is scheduled to complete on Sept 23, 2007. | ||||||
| Volunteer | ### Medical College, state, country | Honorary Student Trainee (psychiatry) | 88888 | 24 | ||
| Description | ||||||
| 4 week voluntary hands-on experience; training included history taking, emergency management of psychiatric patients, providing assistance in managing clinic patients and conducting morning rounds; attending case presentations and seminars(did this because many states require extra hours of psychiatry for licensing eg Illinois) | ||||||
| Reason for Leaving: | ||||||
| Completion of scheduled period of training. | ||||||
| Research | ### Medical College, state, country | Post Graduate Resident | 8888 | When no supervisor name any teacher you consulted with and who will agree to it if verified. | ||
| Description | ||||||
| Research Experience involved conducting a questionnaire based study about the knowledge, attitude and practices seen amongst etc etc | ||||||
| Reason for Leaving: | ||||||
| Completion of study. | ||||||
| Research | ### Medical College, state, country | Post Graduate Resident | 8888 | AAAA | 50 | |
| Description | ||||||
| Research Experience included completion of dissertation study titled ' xxxx”', comprising of “sample size”. The aim was threefold: blah blah. | ||||||
| Reason for Leaving: | ||||||
| Completion of dissertation and residency. | ||||||
Publications
| Peer Reviewed Journal Articles/Abstracts authors,. topic.. Indian J Pediatr. Details of page. Cited in PubMed; PMID: xxxx. Pub Status: Published. |
| Etc etc |
| Presentations/Posters like above |
Language Fluency (Other than English)
| I just mentioned languages I knew didn’t go into description of what exactly fluency meant |
Hobbies & Interests
| Traveling, Singing, Reading and Painting |
Other Awards/Accomplishments -
mention stuff you want them to know but cant fit anywhere else (wrack ur brains,
there is a lot of stuff we are too shy or uninitiated to mention! This also has
word limit so like I mentioned PALS here and not above in the general info because
this was done in my home country not USA, but I still wanted them to
know I did it
| Neonatal Resuscitation program trained (dates); Pediatric Advanced Life Support trained(dates); Attended workshops on Childhood Asthma Management (dates) etc etc; All India Postgraduate Examination-Rank if it is good; Students Union in Medical School; extracurricular activities |
Certification
| I certify that the information contained within my ERAS application is complete and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me from consideration for a position, or if employed, may constitute cause for termination from the program, and will also result in expulsion from ERAS and investigation by the AAMC per the attached policy (pdf file). | |||
| Certified by: | M | Date: | 09/03/2007 |
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