Third Year Medical Student Schedule Request 2009-2010 Core Hospital by broverya85

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									                             Third Year Medical Student Schedule Request
                                             2009-2010
                                 Core Hospital Elective Request Form

Student Name: _____________________________________ I.D. No.__________________________

Electives are very valuable and they should serve a definite purpose to help you in the future. They
should be used:

    1. To help you make a choice of what area of medicine you may wish to enter.

    2. To help you to investigate different programs and pave the way for you to be able to chose the
       one of your choice.

Please list your elective choice including the hospital site and preceptor. All efforts will be made to
place students in the elective of their choice.

If your request is outside of our Core Elective Hospitals, it will require additional approval. A Non-
Core Elective Rotation Request Form will need to be completed in addition to this form. The Non-
Core Elective will be tentatively scheduled until it has been approved.

Line Number _____________________________                       Rotation Month_______________________


                       Subject                           Site                         Preceptor




In making your selection we would like you to explain your choice prior to approval.




______________________________________________                      _______________________________
              Signature of Student                                                Date



Approved 4/30/09-RG/BL/BP
                                 Touro College of Osteopathic Medicine
                            Non-Core Hospital Elective Rotation Request Form
                                               2009-2010
Student Name: _______________________________________ Class Year _____________________
Date Submitted: ______________________________________ ID No.__________ Line No. ______

ALL INFORMATION IS REQUIRED. INCOMPLETE FORMS WILL BE RETURNED. THIS
FORM IS DUE NO LESS THAN THIRTY (30) DAYS PRIOR TO THE ANTICIPATED ROTATION
START DATE.

Rotation Requested: __________________________________ Requested Month: _________________
Hospital/Office Site
       Name: ___________________________________________________________________________
       Address: _________________________________________________________________________
       City: ________________________________ State: _________________ Zip: _______________
       Phone: ________________________ Fax: _____________________ Email: _________________
Preceptor
       Name: ___________________________________________________________________________
       Address: _________________________________________________________________________
       City: ________________________________ State: __________________ Zip: _____________
       Phone: ________________________Fax: _______________________ Email: _______________
       AOA/AMA No.: ______________________________ State Licensed: _______________________

Note: Student will be given the responsibility to assist in gathering the documentation necessary for
credentialing the preceptor. The preceptor must be properly credentialed no less than thirty (30) days
prior to the anticipated rotation start date or the rotation will be cancelled.

In making your selection we would like you to explain your choice prior to approval.




Submission of this request does not constitute approval. Plans for travel or housing should not be
made until the student is in receipt of a signed copy of this form indicating approval.

______________________________________________       _______________________________
             Signature of Student                                  Date
Approved  Denied  _________________________________________________________________
_______________________________________________________________________________________
Signature: _____________________________________________ Date: ____________________________
                    Department of Clinical Rotations
Approved 4/30/09-RG/BL/BP

								
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