Scholarly Year Request

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Students considering a Scholarly Year off from medical training must consult with their Faculty Advisor and the Medical Student Research Office (MSRO) to discuss plans for a Scholarly year before submitting this request form. International students must also consult the International Personnel Office and students doing research outside of the United States should consult with Darinka Gadikota-Klumpers in advanced of submitting this form.

The deadline for submitting this Request for a Scholarly Year is May 15. Please allow 4 weeks for the processing of this form. You will need to upload the following additional documents to this form:

signed Mentor/Mentee Agreement form,
research abstract on your project following guidelines on how to write an abstract on a research project (unless you plan to do an external fellowship program, in which case you should attach your acceptance to the fellowship),
funding form. Note, you must be able to cover your cost of living expenses in the amount of $35,000 or greater for the year.

Students interested in a year for a Consulting/Professional Programs, a second degree (with the exception of the PORTAL program) should consult with Student Affairs as you will be required to complete a different form and NOT the ”Request for Scholarly Year form”.

STUDENT FINANCIAL SERVICES: This office will service all 3 categories. The contact email is studentfinancialservices@mssm.edu

FINANCIAL AID: Students may apply and receive federal student loans.
HEALTH INSURANCE: Health Insurance is required for Scholarly Year. Students attending another institution can remain with Icahn student health insurance or, if the student decides to accept other insurance, they must cancel Icahn health insurance within 30 days of start date (note: failure to do so will result in the student being responsible for all fees). Students will be eligible to re-enroll at the beginning of the next academic cycle.

HOUSING: Students on Scholarly Year are eligible for housing. For more information contact: Housing@mountsinai.org.

LENGTH OF TIME TO DEGREE: Students are allowed a maximum of 6 years to complete the MD program at ISMMS, and a further extension of this leave will not be granted. Exceptions may be made at the discretion of the Promotions Committee.

FOR MORE DETAILED GUIDELINES, go to: https://mountsinai.box.com/s/v8cr3266opgnucotbcf0ylzirticjk4a

Student Information

Student Name*

First Name

Last Name

Life Number*

Student's Address

Address Line 1

Address Line 2

City

State

ZIP Code

Cell Phone*

Student's Email*

Program*

MD MD/MSCR MD/MPH

Current Year in Training*

Requested Start Date*

Anticipated Return Date*

MD Faculty Advisor's email- NOT YOUR MENTOR*

Are you an International Student?*

Yes No

If you are an international student contact the International Personnel Office for any documents and clearances you may need, call 212-731-7744.

Project Information

Institution/Department*

Select other if not Mount Sinai and then type Institution/Department

Other Department

Is your research at MS Health System*

Yes No

Institution if not at MS Health System

Institution/Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

External Funded National Program*

Yes No Not sure

Such as NIH Medical Scholars, Sarnoff, etc

Will any part of your Scholarly Year project be conducted outside the United States? *

Yes No

Contact Jennifer Meyer in the Global Health Office: jennifer.meyer@mssm.edu and complete the Pre-Travel requirements, which can be found on the Global Health Blackboard page.

Upload Research Abstract/ Letter of Acceptance to a Program*

No File Chosen

File uploads may not work on some mobile devices.

Research Type*

Enter Other Research Type

Mentor

Mentor's Name*

First Name

Last Name

Mentor's degree*

Mentor's Division, Program, Center, or Company Name*

Mentor Email Address*

Mentor/Mentee Agreement Form*

No File Chosen

File uploads may not work on some mobile devices.

Source of Funding

Source of Funding*

(name of sponsoring agency, mentor or department)

Amount of Funding: $* $

Total amount of funding

Funding Start date*

Funding End Date *

Upload Funding Form*

No File Chosen

File uploads may not work on some mobile devices.

Student Agreement

I understand that if I begin a Scholarly Year program without having obtained prior written approval that my status can automatically be converted to an administrative leave.

Agreement*

I have read, understand and agree to the terms of this Scholarly Year

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date of Signature*

Faculty Advisor Section

Comments

viewable by student

Faculty Advisor Approval

Approve Deny

Student Affairs Section

Comments

viewable by student

Student Affairs Approval

Approve Deny

MSRO Admin Section

Adjusted Start Date*

may be modified from original request

Adjusted End Date*

may be modified from original request

Comments

viewable by student

MSRO Admin Approval*

Approve Deny

Reason for MSRO Admin Denial*

viewable by student

Director of Medical Student Research Section

Comments

viewable by student

Final Approval by Director of Medical Student Research*

Approve Deny

Final Start Date*

viewable by student

Final End Date*

viewable by student