APPLICATION TO ENROLL IN AN EXTERNSHIP (IDSP 900) FOR ACADEMIC CREDIT

UNIVERSITY OF KANSAS SCHOOL OF MEDICINE

An Externship is a scholastic activity that departs from the elective clerkship offerings of the curriculum at KUMC. A total of TWO externships, not to exceed 8 weeks, are allowed toward the 16 weeks required for the M.D. degree. THIS APPLICATION RECEIVED IN THE OFFICE OF STUDENT AFFAIRS (3040 MURPHY) AT LEAST 6-8 WEEKS PRIOR TO THE BEGINNING DATE OF THE CLERKSHIP. (*Please note that more than two externships are permissible for credit on the student permanent record, but would be in addition to the four required electives of 4 weeks each.)

I, ______, ______,request permission to receive academic credit for a Special Program Name of student KUID

in ______beginning date ______and ending date______

Title of Course/Elective and Course #

at ______located in ______Wks/Cr. Hrs___

Name of hospital, school, or office City, State

An evaluation form will be sent to you upon receipt of this form in Student Affairs to provide to the faculty member who will complete the form and return it as noted on the form. Be sure that you print the name and complete address and phone number.

______( )______

Name Address (include City/State/Zip) or email address Phone

I confirm that the above information is true and accurate to the best of my ability. I understand that I am solelyresponsible for obtaining all of the information above and insuring that my evaluation is completed and returned to Student Affairs. Failure to do so could affect my grade in the rotation and receiving credit for the rotation. A letter from the individual responsible for the program, outlining a description of the duties to be performed, inclusive dates of the clerkship, and verification that an evaluation will be made at the conclusion of the clerkship is attached.

______

Signature of student Cell phone Date

My approval is given for the above named medical student to do this clerkship.

______

Signature of Department Clerkship/Elective Administrator Department Date

FINAL STEP: MUST SEND COMPLETED FORM TO: ,ORDELIVER TO: 3040 Murphy

No fourth year medical student will be allowed to participate in an Externship for credit at an institution not in the continental United States after April 1 of their fourth year. This means that no grade will be recorded on the student’s permanent record for an Externship taken during April, May, or thereafter, if a course is graded outside of the United States. Fourth year students will be covered by malpractice insurance for off-campus courses until graduation, so long as they request enrollment by using this form. Students who enroll in a course, after completing their requirements for graduate, and who fail to appear for the course without formally withdrawing before the first day of the course, will be receive an Unsatisfactory grade.

If you have a negative experience at an externship location it is very important that you inform OSA. This verbal feedback is just one of two methods for obtaining externship evaluations. Students participating in externship rotations are also provided a link via e-mail to an electronic survey, to provide anonymous feedback on their externship experience. The survey responses are kept in Academic and Student Affairs offices on all campuses for review by students planning externships in the future.

Student Affairs actions: Completed form received ______Evaluation sent ______