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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:

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*
Student's Address
Program*
Requested Start Date*
Anticipated Return Date*
Are you an International Student?*

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

Select other if not Mount Sinai and then type Institution/Department
Is your research at MS Health System*
Institution/Address
External Funded National Program*
Such as NIH Medical Scholars, Sarnoff, etc
Will any part of your Scholarly Year project be conducted outside the United States? *

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.

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Mentor

Mentor's Name*
No File Chosen
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Source of Funding

(name of sponsoring agency, mentor or department)
$
Total amount of funding
Funding Start date*
Funding End Date *
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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*
Use your mouse or finger to draw your signature above
Date of Signature*

Faculty Advisor Section

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Faculty Advisor Approval

Student Affairs Section

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Student Affairs Approval

MSRO Admin Section

Adjusted Start Date*
may be modified from original request
Adjusted End Date*
may be modified from original request
viewable by student
MSRO Admin Approval*
viewable by student

Director of Medical Student Research Section

viewable by student
Final Approval by Director of Medical Student Research*
Final Start Date*
viewable by student
Final End Date*
viewable by student