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					                                          Elective Application
                  (UCI Residents applying to go to Non-UCI Sites for a Rotation elective)

The University of California supports house officer extramural rotations (electives) when those rotations
support an educational need of the house officer. The University will provide salary, benefits and medical
liability coverage during that time. The Residency Program will provide educational credit, based upon the
same criteria of educational enhancement, not generally available at UCI. In order to obtain coverage, salary
and credit you must complete an application process. This document will serve as that application. Please allow
4 weeks for all approvals.

Please obtain the information requested on this form, submit it to the Program Director for signature
and approval, and then submit it to Nancy Koehring, Director of Graduate Medical Education, UCI
College of Medicine, UCIMC, Building 2, Room 119, 101 The City Drive, Orange, CA 92868. Ms.
Koehring will prepare the approval letter and send it to the appropriate parties.

Name                                                          Pager Number


Address


Goals and Objectives: Educational Rationale for this Extramural Rotation. Please explain why this experience is not
available at UCI and what is to be gained from the rotation.




Rotation Title                                          Dates for Rotation


Supervising             Name and Title
Attending
Information             Institution


                        Address


                        Phone Number (          )
Program Director:       I agree with the educational rationale and the importance    Program Director Signature
                        of this extramural rotation. The Program will provide
                        educational credit for this rotation.
                                                                                     Date

				
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posted:11/4/2012
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