Evidence Of Internship Form Page 2

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Evidence Of Internship Form Printable pdf

1

2

Section B

Please list any periods of study, exam preparation or leave taken during the internship

Leave

Start date

Finish date

Number of

weeks

Example: Study leave

2 weeks

0

1

0

1

6

0

0

8

1

5

0

6

2

0

0

8

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

Section C

To be completed by the medical school or institution where you completed your internship

Name of supervising

consultant or

medical director

Address of medical

school or institution

Telephone number

Fax number

Email

Signature

Date

Name

Position held

Official stamp (Note that we cannot accept this form as evidence without an official stamp)

Template form - EEA - Evidence of internship

2 of 2

Last updated 20080424

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