Which best describes your current learning status?
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MD/DO Student (Medical Student)
DPM Student (Podiatry Student)
DMD/DDS Student (Dental Student)
PA Student (Physician Assistant Student)
Legal First Name
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Middle Initial ("X" if None)
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Legal Last Name
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Preferred First Name
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Date of Birth (MM-DD-YYYY)
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Today M-D-Y This is necessary for your Swedish systems setup.
Full Social Security Number
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This is necessary for your Swedish systems setup.
Preferred Email Address
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Mailing Address
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Preferred Phone Number
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Name of School/Institution
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Name of School/Institution Coordinator
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Email of School/Institution Coordinator
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Expected Graduation Date
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Today M-D-Y
Rotation START DATE
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Today M-D-Y This is the proposed start date of the rotation
Rotation END DATE
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Today M-D-Y
Name of Swedish Preceptor (Last Name, First Name)
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You MUST have a named preceptor. Your home institution should have arranged preceptors through the Affiliation Agreement. Your clearance for a rotation at Swedish depends on having a preceptor.
Preceptor Credentials*
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MD/DO
DPM
DMD/DDS
PA/PA-C
Other
If Other, please specify.
Select the Department/Specialty of Swedish Preceptor
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Anesthesiology Behavioral Health Cardiology Emergency Medicine Family Medicine Gastroenterology General Surgery Hospitalist Internal Medicine Neurology Neuroscience Neurosurgery Obstetrics and Gynecology Oncology Orthopedics Pediatrics Podiatry Primary Care Psychiatry Sports Medicine Other (please list below)
If Other, please list department/specialty name.
Swedish Campus
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Ballard Cherry Hill Edmonds First Hill Issaquah Other
If Other, please provide location name.
Swedish Department/Specialty Coordinator
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This is a Swedish administrative or clinic management staff member that works in the office of the department/specialty in which you will be doing your rotation. Your preceptor should identify this person for you, if you do not already know. This is not GME staff.
Email of Swedish Coordinator
Attach Professional Liability Insurance document
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This is provided by your home institution. Some institutions attach this to the Letter of Good Standing.
Attach completed Confidentiality Form
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Attach a Letter of Good Standing (LGS), or
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If attaching a background check: Basic option for Washington State, using name and DOB: https://fortress.wa.gov/wsp/watch/ If you are not from Washington State, you will need a current official background check run in the state of your primary residence.
Attach a scan of personal Health Insurance card, or
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Attachment should be for health insurance and NOT auto or home/renters insurance.
Attach current immunization records.
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See Vaccine and Immunization Requirements document from Swedish Medical Center for more information
Photo ID Application Form
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see Photo ID Application provided
Passport-style Photo of yourself.
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See Photo ID App instructions; no copies of photos; in jpg-format; passport-style - in color, front-facing, with plain background.
Confirm completion of Swedish Orientation Modules.
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Initials here
Authorization for Disclosure of Immunization Information
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Initials here
I attest that all information I entered, uploaded or initialed is correct.
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Initials here
