ERAS Applicant Worksheet

This worksheet may be printed and used to begin completing your MyERAS application offline.
All required fields are highlighted in red and marked with an asterisk.
Please note: Some of these fields are required only in certain circumstances.

AAMC Account Information

First Name* Carlos Sex* Male

Middle Name Alberto Email* carlos-perez96@hotmail.com

Last Name* Perez Hernandez Birth Date* 06/11/1996

Suffix I authorize the release of my birth date to programs

Basic Information

Previous Last Name Preferred Phone* +573185712196

Preferred Name Mobile Phone +573185712196

Alternate Phone

Fax

Pager

Address

Current Mailing Address

Address 1* calle 81 carrera 65-26

Address 2

Country* Colombia

State (Required for U.S. & Canadian addresses)

City* Barranquilla

Postal Code

Is your permanent address the same as your current mailing address?* Yes No

Permanent Address
Address 1

Address 2

Country

State

City

Postal Code

Phone
ERAS Applicant Worksheet (continued)

Work Authorization

Are you currently authorized to work in the United States?* Yes No

What is your current work authorization?* Other

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

If yes, please select the visa(s) for which you will seek sponsorship. Select all that apply.*
H-1B J-1
*Eligibility for ECFMG J-1 visa sponsorship is not to be presumed. For details on ECFMG J-1 requirements and restrictions,
please visit http://www.ecfmg.org/evsp/requirements.html.

If no, please identify which of the following will serve as your basis for work authorization for the entirety
of your GME training without any need for visa sponsorship. Select all that apply.*

U.S. Citizen or National, Legal Permanent Resident, Refugee, Asylee

Adjustment of Status applicant (Green Card application) (EAD)

DACA – Deferred Action for Childhood Arrivals

Diplomatic Service

E-2 – Treaty investor, spouse, and children (EAD)

Employment Authorization Document (EAD)

F-1 – Academic student (EAD, OPT)

H-1 – Temporary worker

H-1B – Specialty occupation, DoD worker, etc.

H-2B – Temporary worker - skilled and unskilled

H-4 – Spouse or child of H-1, H-2, H2-3 (EAD)

J-1 – Visa for exchange visitor

J-2 – Spouse or child of J-1 (EAD)

L-2 – Dependent of Intra-Company Transferee (EAD)

O-1 – Extraordinary ability in sciences, arts, education, business, or athletics

TN – NAFTA trade visa for Canadians and Mexicans

Other

If you currently reside in the United States or Canada, please identify your current state or province of residence.
ERAS Applicant Worksheet (continued)

Match Information

NRMP Match
I plan to participate in the NRMP match?* Yes No

If yes, NRMP ID: Pending

Participating as a couple in NRMP? Yes No

If yes, partner’s name:

Specialties partner is applying to:

Urology Match
AUA Member Number:

Additional Information

USMLE/ECFMG ID: 10572774

NBOME ID: (Required for D.O. applicants)

AOA Member Number:

I am ACLS (Advanced Cardiovascular Life Support) certified in the U.S.: Yes No

If yes, ACLS expiration date: 05/03/2022

I am PALS (Pediatric Advanced Life Support) certified in the U.S.: Yes No

If yes, PALS expiration date:

I am BLS (Basic Life Support) certified in the U.S.: Yes No

If yes, BLS expiration date: 05/03/2022

Sigma Sigma Phi Status: No SSP chapter at my school (D.O. applicants only)

Alpha Omega Alpha Status: No AOA chapter at my school

Gold Humanism Honor Society Status: No GHHS chapter at my school

ERAS Applicant Worksheet (continued)

Biographic Information

Self-Identification
This section allows you to indicate how you self-identify. When selecting “Other” as a subcategory, the text field is limited to 120 characters;
however, it is not a required field. If you prefer not to self-identify or if you reside in the European Union, please ignore this section.

How do you self-identify? Please select all that apply.

Hispanic, Latino, or of Spanish origin

Argentinean
Colombian
Cuban
Dominican
Mexican/Chicano
Peruvian
Puerto Rican
Other Hispanic:

American Indian or Alaska Native

Tribal affiliation:

Asian
Bangladeshi
Cambodian
Chinese
Filipino
Indian
Indonesian
Japanese
Korean
Laotian
Pakistani
Taiwanese
Vietnamese
Other Asian:

Black or African American

African American
Afro-Caribbean
African
Other Black:

Native Hawaiian or Pacific Islander

Guamanian
Native Hawaiian
Samoan
Other Pacific Islander:

White

Other:
ERAS Applicant Worksheet (continued)

Language Fluency
What languages do you speak? Select all that apply. For each language that you select, including English, you will be asked to rate your
proficiency in that language using the guidelines provided below.*

Native/Functionally Native: I converse easily and accurately in all types of situations. Native speakers, including the highly educated,
may think that I am a native speaker, too.
Advanced: I speak very accurately, and I understand other speakers very accurately. Native speakers have no problem understanding me,
but they probably perceive that I am not a native speaker.
Good: I speak well enough to participate in most conversations. Native speakers notice some errors in my speech or my understanding,
but my errors rarely cause misunderstanding. I have some difficulty communicating necessary health care concepts.
Fair: I speak and understand well enough to have extended conversations about current events, work, family, or personal life.
Native speakers notice many errors in my speech or my understanding. I have difficulty communicating about health care concepts.
Basic: I speak the language imperfectly and only to a limited degree and in limited situations. I have difficulty in or understanding
extended conversations. I am unable to understand or communicate most health care concepts.

Afrikaans Finnish Laotian Serbian

Albanian Formosan Lithuanian Serbocroatian

American Sign Language French Malayalam Sinhalese

Amharic French Creole Mande Slovak

Arabic German Marathi Spanish/Spanish Creole

Native/Functionally Native

Armenian Greek Mon-Khmer, Cambodian Swahili

Bantu Gujarati Navajo Swedish

Bengali Hebrew Nepali Syriac

Bulgarian Hindi Norwegian Tagalog

Burmese Hmong Patois Tamil

Cajun Hungarian Pennsylvania Dutch Telugu

Chinese Ilocano Persian Thai

Croatian Indonesian Polish Tongan

Cushite Italian Portuguese Turkish

Czech Japanese Punjabi Ukrainian

Danish Kannada Romanian Urdu

Dutch Korean Russian Vietnamese

English Kru, Igbo, Yoruba Samoan Yiddish

Advanced
ERAS Applicant Worksheet (continued)

Military Information
Are you committed to fulfill a U.S. military active duty service obligation/deferment?* Yes No

If yes, number of years remaining: Branch:

Air Force
Other
Navy
Army
Do you have any other service obligations (e.g., military reserves, public health/state programs, etc.)?* Yes No

If yes, describe:
255 Characters Max

Additional Information
Hobbies and Interests: Cycling
510 Characters Max Coffee conosieur

Hometown(s):
50 Characters Max

Education

Higher Education
This section allows multiple entries for each undergraduate and graduate school you have attached.

Since most non-U.S. educational systems do not follow the U.S. model, almost all students and graduates of international medical schools
will indicate “None.”

None

Entry 1
Institution* Location*

Education Type* Field of Study*

Degree Expected or Earned*

No
Yes
If Yes: Degree Month Year

Dates of Attendance: From Month* From Year* To Month* To Year*

Entry 2
Institution* Location*

Education Type* Field of Study*

Degree Expected or Earned*

No
Yes
If Yes: Degree Month Year

Dates of Attendance: From Month* From Year* To Month* To Year*

ERAS Applicant Worksheet (continued)

Medical Education
This section allows entries for each medical school you have attended.

Entry 1
Country* Colombia

Institution* Universidad del Norte

Degree* Medico Cirujano (M.C.)

Degree Month* 06

Degree Year* 2018

Dates of Education
From Month* From Year* To Month* To Year*

Entry 2
Country*

Institution*

Degree*

Degree Month*

Degree Year*

Dates of Education
From Month* From Year* To Month* To Year*

Additional Information
Membership in
Honorary/Professional
Societies:
255 Characters Max

Medical School
Awards:
510 Characters Max

Other Awards/
Accomplishments:
510 Characters Max
ERAS Applicant Worksheet (continued)

Experience

Training
Please add an entry for any current or prior AOA Internship, AOA Residency, AOA Fellowship, ACGME Residency, or ACGME/RCPSC/UCNS
Fellowship in which you have trained, regardless of the length of time spent in the training. Save the file after completing the required fields.
Additional entries may be added as needed.

None

Entry 1
Type of Training*
AOA Fellowship
ACGME/RCPSC/UCNS
ACGME
Internship
Residency
Residency Fellowship
Specialty*

Institution/Program*

Country*

State/Province

City*

Program Director*

Supervisor*

Dates of Residency/Fellowship:
From Month* From Year* To Month* To Year*

Reason for Leaving:

510 Characters Max

Entry 2
Type of Training*
AOA Fellowship
ACGME/RCPSC/UCNS
ACGME
Internship
Residency
Residency Fellowship
Specialty*

Institution/Program*

Country*

State/Province

City*

Program Director*

Supervisor*

Dates of Residency/Fellowship:
From Month* From Year* To Month* To Year*

Reason for Leaving:

510 Characters Max
ERAS Applicant Worksheet (continued)

Experience
Please add any additional experience. Clinical and teaching experience should be treated as work experience. Include all unpaid extracurricular
activities and committees on which you have served as Volunteer Experience.

None

Entry 1
Experience Type*
Work Experience
Research
Volunteer Experience
Organization*

Position*

Supervisor

Country*

State/Province

City*

Average Hours/Week

Description:
1020 Characters Max

Reason for Leaving:

510 Characters Max

Dates of Experience:
From Month* From Year* To Month* To Year*

Entry 2
Experience Type*
Work Experience
Research
Volunteer Experience
Organization*

Position*

Supervisor

Country*

State/Province

City*

Average Hours/Week

Description:
1020 Characters Max

Reason for Leaving:

510 Characters Max

Dates of Experience:
From Month* From Year* To Month* To Year*
ERAS Applicant Worksheet (continued)

Additional Information
Was your medical education/training extended or interrupted?* Yes No
If yes, please
provide details.
510 Characters Max

Licensure
Please add an entry for any of your state medical licenses.

None

Entry 1
State*

License Type*
Temporary or Limited
Full
Inactive
License Number*

Expiration Month*

Expiration Year*

Entry 2
State*

License Type*
Temporary or Limited
Full
Inactive
License Number*

Expiration Month*

Expiration Year*

Additional Information
Has your medical license ever been suspended/revoked/voluntarily terminated?* Yes No

If yes,
please explain:
510 Characters Max

Have you been named in a malpractice case?* Yes No

If yes,
please explain:
510 Characters Max

Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?*
(Note: This section is not intended to solicit information about your health, disability, or family status.) Yes No

If yes,
please explain:
510 Characters Max

Have you ever been convicted of a misdemeanor in the United States?* Yes No

If yes,
please explain:
510 Characters Max
ERAS Applicant Worksheet (continued)

Have you ever been convicted of a felony in the United States?* Yes No

If yes,
please explain:
510 Characters Max

Are you able to carry out the responsibilities of a resident, intern, or a fellow in the specialties and at the specific training programs to
which you are applying, including the functional requirements, cognitive requirements, and interpersonal and communication requirements
with or without reasonable accommodations?*

Yes No No Response

Are you Board Certified?* Yes No

If yes, Board Name:

DEA Registration Number:

Expiration Month Expiration Year

Publications
Add an entry for each of your publications.

Peer-Reviewed Journal Articles/Abstracts

Journal Article(s)/
Abstract(s) Title*
255 Characters Max

Author(s)* (Last Name, First Initial, Middle Initial)

Publication Name*

Publication Med-Line Unique Identifier (PMID)

Publication Volume*

Issue Number*

Pages* (e.g., 200-212)

Month* Year*

Peer-Reviewed Journal Articles/Abstracts (Other than Published)

Journal Article(s)/
Abstract(s) Title*
255 Characters Max

Author(s)* (Last Name, First Initial, Middle Initial)

Publication Name*

Publication Status*
Provisionally Accepted
Submitted
In-Press
Accepted
Month* Year*
ERAS Applicant Worksheet (continued)

Peer-Reviewed Book Chapter

Chapter Title*
255 Characters Max

Name of Book*

Author(s)* (Last Name, First Initial, Middle Initial)

Editor(s)* (First Initial, Middle Initial, Last Name)

Publisher*

Pages* (e.g., 200-212)

Country*

State/Province

City*

Year*

Scientific Monograph

Monograph Title*
255 Characters Max

Publication Name*

Volume*

Issue Number*

(e.g., 200-212)
Part No.
Page(s)
Serial
Whole No.
No.
Author(s)* (Last Name, First Initial, Middle Initial)

Editor(s)* (First Initial, Middle Initial, Last Name)

Publisher*

Year*

Other Articles

Title of Other Article*

255 Characters Max

Author(s)* (Last Name, First Initial, Middle Initial)

Publication Name*

Publication Date* (MM/DD/YYYY)

ERAS Applicant Worksheet (continued)

Poster Presentation
Poster Presentation Title*
255 Characters Max

Author(s)/Presenter(s)* (Last Name, First Initial, Middle Initial)

Event/Meeting*

Country*

State/Province

City*

Month* Year*

Oral Presentation
Oral Presentation Title*
255 Characters Max

Author(s)/Presenter(s)* (Last Name, First Initial, Middle Initial)

Event/Meeting*

Country*

State/Province

City*

Month* Year*

Peer-Reviewed Online Publication

Online Publication Title*
255 Characters Max

Author(s)* (Last Name, First Initial, Middle Initial)

URL*

Publication Date* (MM/DD/YYYY)

Non-Peer-Reviewed Online Publication

Online Publication Title*
255 Characters Max

Author(s)* (Last Name, First Initial, Middle Initial)

URL*

Publication Date* (MM/DD/YYYY)

ERAS Applicant Worksheet (continued)

Certification

I certify that the information contained within the MyERAS 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;
may result in an investigation by the AAMC per the attached policy (PDF); may also result in expulsion from ERAS;
or if employed, may constitute cause for termination from the program. I also understand and agree to the AAMC Web
Site Terms and Conditions and to the AAMC Privacy Statement and the AAMC Policies Regarding the Collection,
Use and Dissemination of Resident, Intern, Fellow, and Residency, Internship, and Fellowship Application Data and
to these AAMC’s collection and other processing of my personal data according to these privacy policies. In addition,
I consent to the transfer of my personal data to AAMC in the United States, to those residency programs in the United
States and Canada that I select through my application, and to other third parties as stated in these Privacy Policies.*