University of Massachusetts Medical School

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					                                   University of Massachusetts Medical School
                                                                                           International Elective / Indian Health
 Elective schedule changes can only be made with written consent of your Advisor/ Specialty Mentor (on your PEP), Mick
 Godkin, the Elective Coordinator, and the Associate Dean for Student Affairs. Two months notice is requested when adding or
 dropping an international elective. An exception may be made if there are extenuating circumstances.
 The LCME only accredits medical schools in the US and Canada. All International electives and Indian Health electives must be
 sponsored and approved by Mick Godkin, PhD., Director of the International Medical Education Program. Dr. Godkin must approve the
 elective in order to receive UMass credit. Your performance will be evaluated by the coordinator at the location the elective is taken.
 Please bring a UMass Elective Evaluation Form with you and give it to the Elective Coordinator working with you for completion.
 (1) Complete ALL information in Section , Check if you are ADDING, DROPPING or CHANGING THE DATE of the elective. [You can
     only Change the Date of a previously approved elective listed on your schedule.]
 (2) Save the file using your name as the file name (e.g. joesmith.doc) to your hard drive**.
 (3) Create an e-mail, attach the saved Elective Form, forward it to Mick Godkin to complete Section .
     Mick Godkin will return the Elective Form to you.
 (4) YOU will forward [electronic or hard copy] the approved Elective Form to the Site Coordinator for approval. Instruct them to return the
     Elective Form directly to YOU.
 (5) IF the elective is approved YOU must forward a copy of the approval information to: or bring a
     copy of the approved elective to the Office of Student Affairs.
 * IF the elective(s) is on your PEP and you have completed all paperwork and paid any fees for the visiting school, you're done!
 * IF the elective(s) is NOT on your PEP, you will need to submit an amended PEP which shows this elective.
 Mick Godkin, Ph.D., Director of International Medical Education:
 (1) Complete the top portion of Section . Attach your electronic signature and check if you Approve / Deny the Request.
 (2) Save the document to your hard drive**, create an e-mail and attach the updated & saved form to the e-mail.
 (3) E-mail the completed Form back to the student. The student will forward the Form to the Elective Coordinator for consideration.
 ** If the document opens in a web navigator page (Explorer or Netscape) you can still save it as a Microsoft Word Document (.doc) in the Save As… menu
 by selecting Microsoft Word as the file type and/or by ending the file name (which will be your name) in .doc

      Student Name:               E-mail:              Pager #:             Class of:           Date: 7/29/12

 *Course number is required for all listed courses                                                              Completed by Faculty

                                                                                  Date                Faculty           Approved         Start Date
         Elective Information                                 Add      Drop
                                                                                 Change              Approvals           Yes No           (m/d/yy
  Course Name:                                                                     From:
  Course No:
                                                                       State        To:            UMass Sponsor
  Dates Elective Requested:                                           reason
  Start:       End:                                                    below
  Elective Contact:                                                             To change
  School/ Hospital Name:                                                          dates of
  Address:                                                                        electives                                               Approved
                                                                                                  *Site Coordinator
  City/ State/ Zip:                                                                only                                                   Start Date
                                                                                                   (See Note Below)
  Good Standing Letter needed? Yes                 No

 * Note: A copy of the Site Coordinator's written approval will be accepted in lieu of electronic signature. See (5) of Student's
   Instructions above for information on where to send approval information. Written approval must be received at least four
   weeks before the start of the elective.

Explanation for requesting to drop elective:

  Associate Dean for Student Affairs:

                                                                                                                                       Revised 2/11/09

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