Petition For Extramural Elective (Page 2 of 2) in pdf

Petition For Extramural Elective Page 2

UNIVERSITY OF CENTRAL FLORIDA

COLLEGE OF MEDICINE

FOURTH YEAR (M4)

If you are completing a Special Independent/Research Study, please complete the following and

attach a

copy of the supervising faculty’s approval of the terms below (i.e. email correspondence).

Title: _________________________________________________________________________________

Study Question: ________________________________________________________________________

Background: ____________________________________________________________________________

____________________________________________________________________________

Anticipated Goals/Outcomes:______________________________________________________________

____________________________________________________________________________

_______________________________________________________________________________________

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 #

Student’s Signature

Date

UCF COM Associate or Assistant Dean for Students Signature Approval

Date

FOR OFFICE USE: APPROVED_______ PEOPLESOFT_______OASIS________STUDENT_____DENIED________

Petition For Extramural Elective Page 2