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universita` degli studi di firenze – i firenze01
1 UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01 ERASMUS TEMPUS ALFA INTERUNIVERSITY COOPERATION AGREEMENTS INTERFACULTY EXCHANGE STUDENT MOBILITY PROPOSAL & ENROLMENT FORM ACADEMIC YEAR 20__ / 20__ (photo) FIELD OF STUDY: _________ (DEGREE/DIPLOMA COURSE IN:________________________) This application should be completed in BLACK CAPITAL LETTERS in order to be easily copied and/or telefaxed. HOME INSTITUTION CODE: .............................................................. Name and full address:.............................................................................................................................................................. ............................................................................................................................................................... .........................................................................................................................................................…… Departmental coordinator of the programme:..................................................................................................................... telephone: ..........................................................telefax: ........................................................e-mail: Institutional coordinator of the programme:......................................................................................................................... telephone : .........................................................telefax : ................................... e-mail: COORDINATOR’S SIGNATURE STAMP OF THE HOME INSTITUTION …………………………………….………... ………………………………………………………………Date……..…………… (APPLICATION NOT ACCEPTED IF MISSING) STUDENT’S PERSONAL DATA Registration N.: ............................................................ Family name: ......................................................... First name(s): ......................................................................... Sex:........ Date of birth: ............................................ Place of birth: …………………………… Nationality:........................................... Data di nascita Luogo di nascita Cittadinanza Current address: .................................................... Permanent address (if different): ................................................ ...................................................................................... ...................................................................................... Tel. .............................................................................. ................................................................................................................ ..................................……....................................................................... Tel.......................................................................................................... E-mail: Host Institution Istituzione ospitante Università degli Studi di Firenze Faculty: MEDICINE Erasmus & International Relations Coordinator of the programme: Prof. R. Corradetti Period of study Periodo di studio (full dates please) from (da) to (a) Country Paese Italy ...../....../........to......./....../........ Duration of stay expected ECTS (n° of months) credits Durata del soggiorno (n°mesi) ........................ crediti ECTS previsti ............................ RECEIVING INSTITUTION NOT to be filled in by the applicant! We hereby acknowledge receipt of the application.The above-mentioned student is: provisionally accepted at our institution. ERASMUS & International Relations Coordinator of the programme or ERASMUS delegate not accepted at our institution. Erasmus / International Relations Office Signature: ………………………………………… STAMP Date: ……………………………………................ Date: ....................................................... DATA FOR ENROLMENT: To be completed by Florence Secretariat Date of beginning of the study period at the University of Florence: .......................................................................... ERASMUS/International Relations Coordinator of the programme or ERASMUS delegate Signature: ……………………………………… STAMP Date: ………………………………………………. 2 UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01 ERASMUS TEMPUS ALFA INTERUNIVERSITY COOPERATION AGREEMENTS INTERFACULTY EXCHANGE Name of student: ............................................................ Registration N°: ............................... Home Institution:.............................................................................. Country : .............................. Main reasons why I wish to study abroad: If necessary, continue on a separate sheet CURRENT AND PREVIOUS STUDY Diploma/degree for which I am currently studying: ...................................................................................... Duration of course: ......... years Years of study prior to departure abroad : ..................................... I have already studied abroad Yes No If Yes, when? ........................... At which institution?...................................................................................... WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant) Type of work experience Company / organization dates country ……………………………….. …………………………………….. ………… ……………………… ……………………………….. …………………………………….. ………… ……………………… Unique deadline for all applications: 31ST May. Please send all Medical Faculty mobility applications to: International Relations Secretariat, Erasmus Service Faculty of Medicine, NIC - Padiglione H3 2nd floor - room no. 218/219 Largo Brambilla, 3 - 50134 Florence, Italy E-mail for pdf. applications: [email protected] Fax: +39 055 4598 931. Phone: +39 055 4598 793 LANGUAGE COMPETENCE Languages Mother tongue Excellent Good Fair Italiano English Français Deutsch Español Other:………....................... Other: ................................ Language of instruction at your home institution (only if different from your mother tongue) ……………………… 3 UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01 ERASMUS TEMPUS ALFA INTERUNIVERSITY COOPERATION AGREEMENTS INTERFACULTY EXCHANGE ECTS - EUROPEAN CREDIT TRANSFER SYSTEM (if adopted) LEARNING AGREEMENT: COURSES page n°___ If you need more than one page for courses, please reprint this form (indicate 1/2 & 2/2). Each page must be signed and stamped. ACADEMIC YEAR 20__ / 20__ Name & Surname of Student: ........................................................... Home Institution:.............................................................. Host Institution: I FIRENZE 01 Registration ................................... Country : ................................ Country: ITALY Faculty of Medicine: Specific Degree for which you are studying:……………………………………… I SEMESTER and/or II SEMESTER Total n° months:____ For which Course year will you be in Florence? I , II , III , IV , V , VI ECTS Code, if any Y/S COURSE UNIT Annual, semestral ECTS Credits Total expected credits Student’s signature : .........................................................................Date…………………………………………. HOME INSTITUTION We confirm that this proposed programme of study is approved. Erasmus/International Relations Institutional/Departmental Coordinator. Name (nome): .......................................................................... Signature (firma): .................................................................. LEARNING AGREEMENT Date:…………………………………. Academic tutor Name (nome): .................................... Signature (firma): ..............................……… HOST INSTITUTION (I FIRENZE 01) We confirm that this proposed programme of study is approved. LEARNING AGREEMENT Firenze,………………….. Erasmus/ International Relations Academic Tutor - Name (nome) ………………………… Erasmus delegate: PROF. RENATO CORRADETTI Signature (firma) Signature (firma) ……………………………………….. 4 UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01 ERASMUS TEMPUS INTERUNIVERSITY COOPERATION AGREEMENTS ALFA INTERFACULTY EXCHANGE ECTS - EUROPEAN CREDIT TRANSFER SYSTEM (if adopted) LEARNING AGREEMENT: CLINICAL ROTATIONS page n° __ If you need more than one page for rotations, please reprint this form (indicate 1/2 & 2/2). Each page must be signed and stamped. ACADEMIC YEAR 20__ / 20__ Name of student: ............................................................ Home institution:............................................................. Host institution: I FIRENZE 01 Registration ................................... Country : ................................ Country: ITALY Faculty of Medicine: Specific Degree for which you are studying:………………………………… I SEM and/or II SEM Total n° months:……………………………… Which Course year will you do in Florence? I , II , III , IV , ECTS Code, if any V , VI CLINICAL ROTATIONS Please specify each rotation you wish to do. A good knowledge of Italian is required before starting your rotations N° of weeks ECTS Credits (maximum 4 weeks per rotation) crediti ECTS .................................. ........................................................................................................................ .................................. ....................................................................................................................... .................................. ....................................................................................................................... …............................... ….................................................................................................................... …............................... ….................................................................................................................... …............................... ….................................................................................................................... …............................... …................................................................................................................... …............................... ….................................................................................................................... …............................... ….................................................................................................................... Total expected credits …………… Student’s signature : .........................................................................Date…………………………………………. HOME INSTITUTION LEARNING AGREEMENT We confirm that this proposed programme of study is approved. Date:……………………….. Erasmus Institutional/Departmental Coordinator Academic tutor Name (nome): ......................................................................... Name (nome): ..........................................STAMP........... Signature (firma): ...................................................................Signature (firma): ....................................................... HOST INSTITUTION (I FIRENZE 01) We confirm that this proposed programme of study is approved. LEARNING AGREEMENT Firenze,………………….. Erasmus/ International Relations Coordinator of the programme - Name (nome) …………………………… Erasmus delegate: PROF. RENATO CORRADETTI Signature (firma) Signature (firma) 5 UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01 ERASMUS TEMPUS INTERUNIVERSITY COOPERATION AGREEMENTS ALFA INTERFACULTY EXCHANGE ECTS - EUROPEAN CREDIT TRANSFER SYSTEM (if adopted) CHANGES TO ORIGINAL LEARNING AGREEMENT to be used only after arrival in Florence ACADEMIC YEAR 20__ / 20__ Name of student: ............................................................ Home institution:............................................................. Host institution: I FIRENZE 01 Registration ................................... Country : ................................ Country: ITALY Faculty of Medicine: Specific Degree for which you are studying:…………………………………. I SEMESTER and/or II SEMESTER Total n° months:………………………… Which Course year will you do in Florence? I , II , III , IV , V , VI ECTS Credits ECTS Code, if any deleted Course Unit added .............................................................................. Crediti ECTS ................. .................. ............................................................................. ................. ................... .................................. ............................................................................ ................. .................. .................................. ............................................................................ ................. ……………. ................................. ………………………………………................….. …………… ……………. ................................. ………………………………………................….. …………… ……………. .................................. ................................ .. Student’s signature : ...............................................................................................Date:..................................... HOME INSTITUTION Changes to original Learning Agreement We confirm that these changes to the original programme of study are approved. Erasmus Institutional/Departmental Coordinator Academic Tutor: Signature (firma).................................................................. Signature …...............................................Date……............. Stamp.................................................................................... University stamp: HOST INSTITUTION Changes to original Learning Agreement We confirm that these changes to the original programme of study are approved. Erasmus/International Relations Coordinator of the programme or Erasmus delegate: Name (nome) Signature (firma) Stamp: 6 UNIVERSITA’ DEGLI STUDI DI FIRENZE - I FIRENZE 01 IMPORTANT NOTICE Infection Control Protocol for Medical Students coming to study at the Faculty of Medicine, Florence University. Hepatitis B, tuberculosis, measles, mumps and rubella are known to be relevant occupational infectious diseases for medical students. We hereby inform you of the requests for immunization adopted by the Faculty of Medicine at our University: • Hepatitis B: vaccination is mandatory for all medical students. Vaccination coverage can be investigated by measuring the title of antiHbs (> 10 mUI/ml) and antiHbc antibodies. • Tuberculosis: vaccination is not mandatory, but it is strongly recommended for tuberculin-negative medical students who attend or are supposed to attend “high-risk “ departments (Department for Infectious Diseases, Emergency, etc.). Vaccination is particularly recommended for those medical students who, if infected, cannot be treated with anti-tubercular drugs because of medical contraindications. • Measles, Mumps and Rubella** or German Measles (MMR vaccine): vaccination is not mandatory for medical students, but strongly recommended. The status of immunization against these viruses can be checked by serologic testing for specific antibodies. • **Female Students: Vaccination against rubella is mandatory for all female students who have not been immunized already against this virus. N.B. It is the responsibility of those in-coming students with any past or present medical conditions that require particular care, or medication, to provide official certification from their family doctor to the effect that they can safely attend hospital wards throughout their mobility programme, taking into consideration the health of patients, staff and fellow-students as well as their own. This certification will be treated confidentially.
