ERAS® Applicant Worksheet

AAMC Account Information

First Name*

Middle Name

Last Name*

Suffix

Gender*

Email*

Birth Date*

I authorize the release of my birth date to programs

Basic Information

Previous Last Name

Preferred Name

Preferred Pronoun

Preferred Phone*

Mobile Phone

Alternate Phone

Fax

Pager

Address

Current Mailing Address

Address 1*

Address 2

Country*

State

City*

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

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.

(Required for U.S. & Canadian addresses)

Work Authorization

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

What is your current work authorization?*

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

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:

NBOME ID:

American Osteopathic Association Member Number:

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

If yes, ACLS expiration date:

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:

Sigma Sigma Phi Status:

Alpha Omega Alpha Status:

Gold Humanism Honor Society Status:

(Required for D.O. applicants)

(D.O. applicants only)

ERAS

Applicant Worksheet (continued)

If yes, NRMP

ID:

• If you are already registered for the NRMP Match

and have your NRMP

ID, please enter it.

• If you currently do not have your NRMP

ID, please enter it as soon as you receive it. NRMP

ID is not required to certify & submit your

application and can be added once you have received your NRMP

ID.

• Please note that registering or participating with MyERAS does not automatically register you for The Match

. You will need to register with

the NRMP

separately at https://www.nrmp.org.

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

Albanian

American Sign Language

Amharic

Arabic

Armenian

Bantu

Bengali

Bulgarian

Burmese

Cajun

Chinese

Croatian

Cushite

Czech

Danish

Dutch

English

Finnish

Formosan

French

French Creole

German

Greek

Gujarati

Hebrew

Hindi

Hmong

Hungarian

Ilocano

Indonesian

Italian

Japanese

Kannada

Korean

Kru, Igbo, Yoruba

Laotian

Lithuanian

Malayalam

Mande

Marathi

Mon-Khmer, Cambodian

Navajo

Nepali

Norwegian

Patois

Pennsylvania Dutch

Persian

Polish

Portuguese

Punjabi

Romanian

Russian

Samoan

Serbian

Serbocroatian

Sinhalese

Slovak

Spanish/Spanish Creole

Swahili

Swedish

Syriac

Tagalog

Tamil

Telugu

Thai

Tongan

Turkish

Ukrainian

Urdu

Vietnamese

Yiddish

ERAS

Applicant Worksheet (continued)

*Additional language options: Fulani, Hawaiian, Bisayan, Irish Gaelic, Jamaican Creole, Karen.

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:

Do you have any other service obligations (e.g., military reserves, public health/state programs)?* Yes

If yes, describe:

255-character limit

ERAS

Applicant Worksheet (continued)

Geographic Preferences

The division preferences section offers you an opportunity to communicate your preference or lack of preference for particular

geographic divisions. Indicate your preference (or lack of preference) for up to three U.S. Census divisions.

• If you select a particular division, then only programs located in the division and to which you apply will see your response.

• If you select "I do not have a division preference," then all programs to which you apply will see your response.

• If you skip this section, then no information will be provided to any program.

Entry 1

U.S. Census division:

Please describe your preference or lack of preference for the division you selected (300-character limit):

Entry 2

U.S. Census division:

Please describe your preference or lack of preference for the division you selected (300-character limit):

Hometown(s)

Country*:

City*:

State/Province:

Postal Code:

Setting:

Hometown is an area(s) where you currently or previously lived and feel strong ties or sense of belong. You may enter up to five

hometowns. Refer to page 10 for guidance around setting.

ERAS

Applicant Worksheet (continued)

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

Location*

Field of Study*

Month Year

Institution*

Education Type*

Degree Expected or Earned*

If Yes: Degree

Dates of Attendance: From Month*

From Year* To Month* To Year*

Entry 2

Location*

Field of Study*

Month Year

Institution*

Education Type*

Degree Expected or Earned*

If Yes: Degree

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

U.S. Census division:

Please describe your preference or lack of preference for the division you selected (300-character limit):

Entry 3

Setting Preferences

The setting preferences section is designed to give applicants the opportunity to communicate their preference or lack of preference for

urban or rural settings.

Indicate your preference or lack of preference for rural or urban settings.

Please describe your setting preference or lack of preference (300-character limit):

Education

Medical Education

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

Entry 1

Country*

Institution*

Degree*

Degree Month*

Degree Year*

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*

ERAS

Applicant Worksheet (continued)

ERAS

Applicant Worksheet (continued)

Additional Information

Membership in

Honorary/Professional

Societies:

255-characters limit

Medical School

Awards:

510-characters limit

Other Awards/

Accomplishments:

510-characters limit

Postgraduate Training

Please add an entry for each of your current or prior trainings. If necessary, please work with your supervisor to determine an end date

for a training you are currently completing.

If your program was accredited by the American Osteopathic Association (AOA) when you completed your training, please select the

option with "AOA" noted in the Type of Training and Specialty menus.

None

Entry 1

From Year*

To Month*

To Year*

Type of Training*

Specialty*

Institution/Program*

Country*

State/Province

City*

Postal Code*:

Location Setting:

Program Director*

Supervisor*

Dates of Residency/Fellowship:

From Month*

Experiences

ERAS

Applicant Worksheet (continued)

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Prvince*

Country*

City*

Participation Frequency

Primary Focus Area

Context, Roles and

Responsibilities:

750-character limit

Postal Code*

Setting

Key Characteristics

Please identify and describe up to 10 experiences that communicate who you are, what you are passionate about, and what is most

important to you.

Entry 1

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Postal Code*

Entry 2

Setting

Key Characteristics

Country*

City*

Participation Frequency

Primary Focus Area

Context, Roles and

Responsibilities

750-character limit

Guidance for Settings:

• URBAN: The central part of a city; high population density; high density of structure such as houses, buildings, railways; public transportation more

readily available for commuting; most jobs are non-agricultural.

• SUBURBAN: Smaller urban area around a city; less populated than a city; serves mainly as residential area for city’s workforce; mostly residential with

single-family homes, stores, and services; more parks and open spaces than a city; limited public transportation and private vehicles needed for

commuting.

• RURAL: Large amounts of undeveloped land; low population density; open areas of land with few homes or buildings; no public transportation; private

vehicles needed for commuting; main industries likely to be agriculture or natural-resource extraction.

ERAS

Applicant Worksheet (continued)

Context, Roles and

Responsibilities

750-character limit

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Country*

City*

Participation Frequency

Primary Focus Area

Postal Code*

Entry 3

Context, Roles and

Responsibilities

750-character limit

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Country*

City*

Participation Frequency

Primary Focus Area

Postal Code*

Entry 4

Setting

Key Characteristics

Setting

Key Characteristics

ERAS

Applicant Worksheet (continued)

Context, Roles and

Responsibilities

750-character limit

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Country*

City*

Participation Frequency

Primary Focus Area

Postal Code*

Entry 5

Context, Roles and

Responsibilities

750-character limit

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Country*

City*

Participation Frequency

Primary Focus Area

Postal Code*

Entry 6

Setting

Key Characteristics

Setting

Key Characteristics

ERAS

Applicant Worksheet (continued)

Context, Roles and

Responsibilities

750-character limit

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Country*

City*

Participation Frequency

Primary Focus Area

Postal Code*

Entry 7

Context, Roles and

Responsibilities

750-character limit

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Country*

City*

Participation Frequency

Primary Focus Area

Postal Code*

Entry 8

Setting

Key Characteristics

Setting

Key Characteristics

ERAS

Applicant Worksheet (continued)

Context, Roles and

Responsibilities

750-character limit

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Country*

City*

Participation Frequency

Primary Focus Area

Postal Code*

Entry 9

Context, Roles and

Responsibilities

750-character limit

Organization*

Experience Type*

Position Title*

I am currently working in this role

Start Date*

End Date*

State/Province*

Country*

City*

Participation Frequency

Primary Focus Area

Postal Code*

Entry 10

Setting

Key Characteristics

Setting

Key Characteristics

ERAS

Applicant Worksheet (continued)

2 of 3 Meaningful Experience

Description:

3 of 3 Meaningful Experience

Description:

Selected Experiences | What made this experience meaningful?

Identify and describe up to three of the 10 experiences that you found the most meaningful.

Reflect on the experience, why it was meaningful, and how it influenced you. Weave in the focus area or key characteristic

you tagged. This should not describe what you did in the experience or list a set of skills that you developed or demonstrated

during the experience.

1 of 3 Meaningful Experience

Description:

300-character limit

ERAS

Applicant Worksheet (continued)

Impactful Experiences

Program directors are interested in learning more about other impactful experiences applicants may have encountered or overcome on

their journey to residency. This section is designed to give applicants the opportunity to provide additional information about their

background or life experiences that is not captured elsewhere in the application (e.g., information written in this section should not be the

same as what is included in the personal statement).

Please describe any challenges or hardships that influenced your journey to residency. This could include experiences related to family

background, financial background, community setting, educational experiences, and/or general life experiences.

Please consider whether this section applies to you. Programs do not expect all applicants to complete this section. This section is

intended for applicants who have overcome major challenges or obstacles. Some applicants may not have experiences that are relevant to

this section. Other applicants may not feel comfortable sharing personal information in their application.

The following examples can help you decide whether you should respond to the section and what kinds of experiences are appropriate to

share on the MyERAS application. Please keep in mind that this is not a fully inclusive list:

• Family background (e.g., first generation to graduate college).

• Financial background (e.g., low-income family, worked to support family growing up, work-study program to pay for college).

• Community setting (e.g., food scarcity, poverty or crime rate, lack of access to medical care).

• Educational experiences (e.g., limited educational opportunities, limited access to advisors or mentors).

• Other general life circumstances (e.g., loss of a family member, serving as a caregiver while working or in school).

750-character limit

Additional Information

Yes No

If yes,

please explain:

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

If yes,

please explain:

Licensure

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

None

Entry 1

State*

License Type*

License Number*

Expiration Month*

Expiration Year*

Entry 2

State*

License Type*

License Number*

Expiration Month*

Additional Information

Was your medical education/training extended or interrupted?* Yes No

If yes, please

provide details:

510-character limit

ERAS® Applicant Worksheet (continued)

510-character limit

please explain:

510-character limit

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

510-character limit

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

Has your medical license ever been suspended, revoked, or voluntarily terminated?*

No Response

Publications

Add an entry for each of your publications.

Peer-Reviewed Journal Articles/Abstracts

Journal Article(s)/

Abstract(s) Title*

255-character limit

Author(s)*

Publication Name*

Publication MEDLINE Unique Identifier (PMID)

Publication Volume*

Issue Number*

Pages*

Month* Year*

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

Journal Article(s)/

Abstract(s) Title*

255-character limit

Author(s)*

Publication Name*

Publication Status*

Month*

Year*

Yes No

If yes,

please explain:

Are you

board

certified?*

Yes No

If yes,

board

name:

DEA Registration Number:

Expiration Month Expiration Year

ERAS

Applicant Worksheet (continued)

(Last Name, First Initial, Middle Initial)

(e.g., 200-212)

510-character limit

Have you ever been convicted of a misdemeanor in the United States?*

If yes,

please explain:

510-character limit

Have you ever been convicted of a felony in the United States?*

Yes No

Article URL

Peer-Reviewed Book Chapter

Chapter Title*

255-character limit

Name of Book*

Author(s)*

Editor(s)*

Publisher*

Pages*

Country*

State/Province

City*

Year*

Scientific Monograph

Monograph Title*

255-character limit

Publication Name*

Volume*

Issue Number*

Author(s)*

Year*