ERAS TEMPLATE

ERAS TEMPLATE

Category	Field	Details
PERSONAL INFORMATION
AAMC Account Information	AAMC ID
	Email Address
	Create your AAMC account: AAMC Website
Basic Information	Full Name (as per your legal documents)
	Phone Number
	Mobile Phone
	Alternate Phone
	Fax Number (if applicable)
	Pager Number (if applicable)
	Pronouns (e.g., he/him, she/her, they/them)
Address	Current Mailing Address
	Permanent Address
Work Authorization	Are you currently authorized to work in the United States? (Yes/No)
	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)
	Type of Visa Sponsorship Required (if applicable)
	If you currently reside in the United States or Canada, please specify:
	State/Province
	City
NRMP MATCH INFORMATION	Do you plan to participate in the NRMP Match? (Yes/No)
	NRMP ID	Register separately with NRMP: NRMP Website
	Are you participating in the match with a partner? (Yes/No)
	Partner’s Name (if applicable)
	Specialties Partner is Applying To
Identification Numbers	USMLE/ECFMG ID
BIOGRAPHIC INFORMATION
Self-Identification	How do you self-identify?	American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Middle Eastern or North African, Native Hawaiian or Pacific Islander, White, Some other race or ethnicity (Specify)
	Do you meet or exceed the Advanced level of proficiency in English?	Yes/No
	Languages in which you meet or exceed the Good level of proficiency:	Hindi, Nepali, Other (Specify)
	Language Proficiency*	Native/Near native, Advanced, Good, Fair, Basic
Military Information	Are you committed to fulfilling a U.S. military active duty service obligation?	Yes/No
	Do you have any other service obligations (e.g., Military Reserves, Public Health/State programs)?	Yes/No
Geographic Preferences	Preferred U.S. Census divisions (select up to 3):	New England, Middle Atlantic, East North Central, West North Central, South Atlantic, East South Central, West South Central, Mountain, Pacific, No preference
Setting Preference	Preferred setting:	Rural, Suburban, Urban, No preference
Hometown(s)	City
	State/Province
	Country
	Postal Code
	Setting: [ ] Urban [ ] Suburban [ ] Rural
EDUCATION
Higher Education	Institution Name
	Dates Attended
	Degree Date
Medical Education	Institution Name
	Dates Attended
	Degree Date
Postgraduate Training	Institution Name
	Type of Training
	Dates Attended
	Degree Date
Extensions & Interruptions	Have you had any unplanned interruptions or extensions?	Yes/No
Honors & Awards	Honor Societies	Alpha Omega Alpha Status: [--Select--], Gold Humanism Honor Society Status: [--Select--]
	Other Honors and Awards	[Add Award]
Professional Memberships	Organization Name	[Add Entry]
EXPERIENCES
Selected Experiences	Key Experiences	[Add Details]
Most Meaningful Experiences	Please list up to 3 most meaningful experiences	[Add Details]
Impactful Experience	Challenges/Hardships	[Add Details]
Hobbies & Interests	Hobbies & Interests	[Add Details]
Licenses and Certifications
State Medical Licenses	State
	License Number
	Date Issued
	Expiration Date
Additional Questions	Are you able to carry out the responsibilities of a resident or fellow with or without reasonable accommodations?	Yes/No/No Response
	Has your medical license ever been suspended, revoked, or voluntarily terminated?	Yes/No
	Have you been named in a malpractice case?	Yes/No
	Is there anything in your past history that would limit your ability to be licensed or receive hospital privileges?	Yes/No
	Have you ever been convicted of a misdemeanor in the United States?	Yes/No
	Have you ever been convicted of a felony in the United States?	Yes/No
Board Certifications	Are you Board Certified?	Yes/No
	Specialty
	Certifying Body
	Date Certified
	Expiration Date
Other Certifications	Do you have any other medical or healthcare-related certifications?	Yes/No
	Certification
	Certifying Body
	Date Issued
	Expiration Date
DEA Registration	DEA Registration Number
	Expiration Month/Year
Publications	Publication Type	Peer-Reviewed Journal Articles/Abstracts, Peer-Reviewed Book Chapter, Scientific Monograph, Poster Presentation, Oral Presentation, Peer-Reviewed Online Publication, Non-Peer Reviewed Online Publication, Other Articles
	Online Publication Title (required)
	Author(s) (required)
	URL (required)
	Publication Date (required)