Petition For Extramural Elective

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UNIVERSITY OF CENTRAL FLORIDA
COLLEGE OF MEDICINE
FOURTH YEAR (M4)
PETITION FOR EXTRAMURAL ELECTIVE
______ MDX 8011 SPECIAL CLINICAL STUDY CREDIT FOR EXTRAMURAL CLERKSHIP
______ MDX 8900 SPECIAL INDEPENDENT/RESEARCH STUDY FOR AWAY CLERKSHIP
This form must be completed and approved 6 weeks prior to the extramural clerkship start date.
Failure to do so may result in a “not for credit” elective month.
 You must complete all sections of this petition form before you will be registered for the course for
credit.
(You must be registered in order for liability coverage to be in effect.)
 No credit will be granted for work for which a student has been paid.
 Student may not be supervised by a parent or relative.
STUDENT NAME: _________________________________________________
PID: _______________
Rotation Start Date: __________________________
Rotation End Date: ________________________
VSAS Institution:
Yes
No
Duration of Elective:
4 Weeks
2 Weeks
Other: ________
Initial that you understand and/or have completed each of the following:
____ The supervising physician is a faculty member at an accredited medical school/residency program.
____ I understand that it is my responsibility to provide the supervising faculty with an evaluation form
before the end of the rotation, and to provide them with instructions on submitting the form to the COM.
____ I have arranged for housing for the duration of the rotation.
If you are completing a Special Clinical Study, please complete the following and
attach a clerkship
description.
If this is a non-VSAS institution you must also attach
a copy of your acceptance to the
program.
_______________________________________________________________________________________
Course/Elective Title
_______________________________________________________________________________________
Away Institution Name
_______________________________________________________________________________________
Address, City, State & Zip Code
______________________________________________________________________________________
Away Institution Supervising Faculty or Contact Person
______________________________________________________________________________________
Away Supervising Faculty or Contact Person E-mail Address
Contact Telephone #

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