UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE ______elebk
APPLICATION FOR AWAY ELECTIVE ______stubk
For LCME and Military rotations: Complete Section I, obtain your advisor's approval, and return form to the Office of Student Affairs for signature. Also request any information required by the away program. Have the program complete Section III or submit a letter of acceptance. This rotation must be approved before the beginning of the rotation. Check the master book in Student Affairs to insure approval before you begin the rotation.
Section I. STUDENT INFORMATION
Name: Phone:
Address E-mail
street city state zip
Elective requested Amount of Elective Credit:
Inclusive dates: to Alternate Dates: to
Application being made to: Name
Address
LCME: Yes No
We have discussed and my advisor has approved this elective.
STUDENT SIGNATURE: DATE
Section II. MEDICAL SCHOOL APPROVAL
The medical student named above is a fourth year student in good standing at the University of Virginia School of Medicine. S/He will pay tuition at our school during the period indicated. Prior to beginning 4th year the student must complete the clerkships (Medicine, Surgery, Pediatrics, OB/GYN, Psychiatry and Family Medicine) and pass Step 1 USMLE. The student is covered by malpractice insurance (1.8M/incidence and unlimited aggregate) while away from our school. S/He is required to carry personal health insurance and to complete annual OSHA Standard Precautions and HIPAA training. S/He is approved to take this elective for credit. The student will provide an evaluation form.
SIGNATURE: DATE
Electives Coordinator, Office for Student Affairs
Section III. ELECTIVE SUPERVISOR APPROVAL
Action: NOT APPROVED
APPROVED FOR (name of elective)
Inclusive dates of elective: From: thru
Student will report to: PERSON
PLACE: TIME
SIGNATURE DATE: PHONE
NAME TITLE
PHONE # where medical student can be reached in an emergency:
Please return form to: OFFICE FOR STUDENT AFFAIRS
UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE
P O Box 800739
CHARLOTTESVILLE, VA 22908-0739
E-mail: ; Phone: (434) 924-5579; FAX: (434) 982-4073