Pediatric Ambulatory Clerkship Rotation

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					                                   Pediatric Ambulatory Clerkship Rotation
                                         Site Preference Ranking List
In the area below please fill in the information requested and rank your top preferences for sites at which you hope to
complete your 3 week Pediatric Ambulatory Clerkship. You must rank at least 3 non-commutable sites. If you require
a commutable site, or have selected a student-created site (SC) as one of your choices, you must justify your request
in the area provided below.

Student Name: (Please Print)

Pager:                      Home Phone:                          Campus Mail Box:

List Languages you speak:

Where do you plan to do the 8 week Pediatric Clerkship? Austin based students will complete the entire 8 week rotation
in Austin. As such, your ambulatory site will be commutable to that area. However, we ask that you still rank 3-5 non-
commutable sites from Galveston in the event that you are unable to go to Austin for your chosen block.
( ) GALVESTON                      ( ) AUSTIN

Ambulatory Site Preference
( ) COMMUTABLE          ( ) NON-COMMUTABLE                     ( ) STUDENT-CREATED

If you require a commutable site, you must justify your request in the area provided below. Commutable sites are
limited and will only be granted to those students for whom we determine have special circumstances.

Please rank the non-commutable sites listed below in the order preferred. You must rank at least 3 non-commutable sites.

Housing is provided locally for the following sites except as noted:

         _______ Austin
                 Beaumont                               Longview/Tyler*                  Waco
                 Conroe                                 Lubbock/Levelland*       _______ West Texas: Plainview
                 Dallas/Fort Worth*                     Nacogdoches                      Other: _________________
                 Houston*                               Victoria / Port Lavaca
         * housing not provided

         Check box if you will be utilizing the provided sponsored housing for preferred site

If you included a student created site in your list of preferences, give the site location and your justification for
wanting to create your own site. If there have been previous students who have created sites in your geographical area
of interest, we may be aware of potential preceptors who have experience working with UTMB students. It will still be your
responsibility to contact the preceptor, but you may check with our office to see if there are any suggestions.

Please Note:
    1. The preferences you mark above will be used to guide your geographic site placement, but no guarantees about
        placement can be made. Site preferences may be changed up to 60 days before the rotation begins; after that
        point, you must accept assignment based on your current preferences. If you would like to make a change to
        your site preferences > 60 days in advance or would like to know your confirmed site assignment before the
        start of the clerkship rotation, please contact Karen Hunley at 747-0268 or

  My signature indicates that I have read and agree to the terms of this Pediatric preference form.

Student Signature: _______________________________
                      Complete the AHEC Biosketch on the back, and return this Preference Form
   SEE                   to the Office of Regional Medical Education no later than 040/3/09.                        SEE
  BACK                  Office Location: 2.104 Marvin Graves Bldg.          Phone: 747-0268                        BACK

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