STUDENT ELECTIVE TERM REPORT

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					FORM CS1                                                             THE UNIVERSITY OF
                                                                     NEW SOUTH WALES




                                                                         OFFICE OF THE DEAN
                                                                         FACULTY OF MEDICINE

                 STUDENT ELECTIVE TERM REPORT


FAMILY NAME:

GIVEN NAME(S):

STUDENT ID:

DATES:                         FROM:                         TO:

NUMBER OF WEEKS:

ELECTIVE PLACEMENT DETAILS:
SUPERVISOR NAME:

SPECIALISATION:

HOSPITAL ADDRESS:



COUNTRY:


CONTACT INFORMATION FOR ELECTIVE PLACEMENT
(To help future students please give a contact name and any other useful advice
eg web addresses, how to apply, what information to send)


CONTACT NAME:

CONTACT DETAILS: