Special Program/externship Form printable pdf download

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.)

TO BE COMPLETED BY STUDENT - PLEASE PRINT

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 the person listed below. Be sure that you print the name and complete address and phone number.

__________________________________________________________________________________________(

)_____________

Name

Address (include City/State/Zip)

Phone

I confirm that the above information is true and accurate to the best of my ability. I understand that I am solely responsible

for obtaining all of the information above and that if I DO NOT it 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

Home phone

Date

TO BE COMPLETED BY CLERKSHIP/ELECTIVE ADMINISTRATOR OF THE DEPARTMENT AT KUMC

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

__________________________________________________ _____________________________ ________________

Signature of Department Clerkship/Elective Administrator

Department

Date

STUDENT: HAND CARRY TO STUDENT AFFAIRS, 3040 MURPHY, FOLLOWING DEPARTMENTAL APPROVAL

I AUTHORIZE THE ABOVE NAMED MEDICAL STUDENT TO BE SCHEDULED FOR THE ABOVE EXTERNSHIP

ASSISTANT DEAN’S ACTION

__________________________________________________________

________________________

Signature of Assistant Dean for Student Affairs

Date

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.

Special Program/externship Form

Related Articles

Related forms

Related Categories