Medical Internship Application

Department of Communication Disorders & Sciences
Eastern Illinois University

If you would like to request a specific site and/or would like to speak with Ms. Bunfill to discuss your internship preferences, please send an email to medicalinternship@eiu.edu to schedule a time to meet.

Name Name * First Last
Permanent Address Permanent Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
EIU Address (if different from permanent address) EIU Address (if different from permanent address)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Email *

Please rank the following levels of healthcare from 1-5 in order of preference: *
	1	2	3	4	5
Acute care (rapid pace; critially ill patients; fast turn-around)	Acute care (rapid pace; critially ill patients; fast turn-around)1	Acute care (rapid pace; critially ill patients; fast turn-around)2	Acute care (rapid pace; critially ill patients; fast turn-around)3	Acute care (rapid pace; critially ill patients; fast turn-around)4	Acute care (rapid pace; critially ill patients; fast turn-around)5
Inpatient rehabilitation (PT, OT, ST, LOS few weeks)	Inpatient rehabilitation (PT, OT, ST, LOS few weeks)1	Inpatient rehabilitation (PT, OT, ST, LOS few weeks)2	Inpatient rehabilitation (PT, OT, ST, LOS few weeks)3	Inpatient rehabilitation (PT, OT, ST, LOS few weeks)4	Inpatient rehabilitation (PT, OT, ST, LOS few weeks)5
Outpatient rehab (patients come in 2-3/week for services)	Outpatient rehab (patients come in 2-3/week for services)1	Outpatient rehab (patients come in 2-3/week for services)2	Outpatient rehab (patients come in 2-3/week for services)3	Outpatient rehab (patients come in 2-3/week for services)4	Outpatient rehab (patients come in 2-3/week for services)5
Skilled Nursing Facility (like inpatient but not in a hospital)	Skilled Nursing Facility (like inpatient but not in a hospital)1	Skilled Nursing Facility (like inpatient but not in a hospital)2	Skilled Nursing Facility (like inpatient but not in a hospital)3	Skilled Nursing Facility (like inpatient but not in a hospital)4	Skilled Nursing Facility (like inpatient but not in a hospital)5
LTACH (long-term care -- trachs, vents, acutely ill patients)	LTACH (long-term care -- trachs, vents, acutely ill patients)1	LTACH (long-term care -- trachs, vents, acutely ill patients)2	LTACH (long-term care -- trachs, vents, acutely ill patients)3	LTACH (long-term care -- trachs, vents, acutely ill patients)4	LTACH (long-term care -- trachs, vents, acutely ill patients)5

Please list in order of preference three locations (city, state) where you could live during your internship:
#1 Location Preference *
#2 Location Preference
#3 Location Preference
What is your priority for medical internship placement? *

What is your priority for medical internship placement? Closer to home, potentially not desired setting/as high quality of an internship Desired setting/better placement quality with a longer commute No preference
If you observed/shadowed at a hospital, indicate where. Any discussion of you interning with them? Please provide names and details.
Which diagnoses and/or types of patients do you hope to be exposed to during medical internship? *

Which diagnoses and/or types of patients do you hope to be exposed to during medical internship? Dysphagia Cognitive-communication disorders/TBI Stroke/Aphasia/RHD Motor Speech/Voice Pediatric NICU Trachs/Vents Other Other
On a scale of 1-10 with 1 being minimal interest and 10 being significant interest, rate how interested you are in working in a medical setting following graduation: *
Please list any possible concerns you may have related to medical internship (e.g., anxiety, pace, etc.):
Please list any other information you would like considered related to internship placement:

Medical Internship Application

Medical Internship Application

Please list in order of preference three locations (city, state) where you could live during your internship: