Rotation Registration Form

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D
M
S
IVISION OF
EDICAL
CIENCES
R
R
F
OTATION
EGISTRATION
ORM
T
.
O BE SUBMITTED PRIOR TO START OF ROTATION
I
,
.
F THE INFORMATION ENTERED IS NOT LEGIBLE
THIS SHEET WILL BE RETURNED TO YOU
T
.
YPE OR PRINT LEGIBLY
S
:
DMS P
A
: Biological & Biomedical Sciences
TUDENT
ROGRAM
FFILIATION
o
o
C
: (C
)
P
D
MD/P
D
G
Y
:
ANDIDATE FOR
HECK ONE
H
H
RADUATE
EAR
o
o
D
R
?
Y
N
O YOU PLAN TO DO A
OTATION THIS SEMESTER
ES
O
o
o
o
R
:
(C
)
1
2
3
S
:
/
/
E
D
:
/
/
OTATION
HECK ONE
TART DATE
ND
ATE
(
10
)
THE AVERAGE LENGTH OF A ROTATION IS
WEEKS
o
o
o
R
R
:
P
T
L
T
O
EASON FOR THIS
OTATION
OTENTIAL
HESIS
AB
ECHNIQUE
THER
o
o
o
o
P
:
25% (
)
50%
100% (
)
O
ERCENT OF TIME PLANNED IN LAB
TYPICAL
TYPICAL IN SUMMER
THER
H
L
:
HMS D
A
:
EAD OF
AB
EPARTMENT
FFILIATION
D
S
(
)
AILY
UPERVISOR
IF DIFFERENT
L
A
:
AB
DDRESS
F
P
N
.
S
L
P
N
.
ACULTY
HONE
O
TUDENT
AB
HONE
O
o
o
o
o
R
: V
:
Y
N
H
S
:
Y
N
ESEARCH INVOLVES
ERTEBRATE ANIMALS
ES
O
UMAN
UBJECTS
ES
O
B
D
R
P
: (P
RIEF
ESCRIPTION OF THE
OTATION
ROJECT
T
P
L
)
LEASE
YPE OR
RINT
EGIBLY
S
S
D
L
H
D
TUDENT
IGNATURE
ATE
AB
EAD
ATE
P
A
S
D
R
S
(
)
D
ROGRAM
DVISOR
IGNATURE
ATE
OTATION
UPERVISOR
IF DIFFERENT
ATE
If this is a potential thesis lab, the principal investigator should be aware of future student support obligations.
DMS Financial Affairs Office can provide details.
Please sign and return with the Lab Head and Program Advisor signatures (and if needed, the Rotation Supervisor’s
signature as well) to:
B
& B
S
, GORDON HALL, RM. 005, H
M
S
, 617-432-0179 (
)
IOLOGICAL
IOMEDICAL
CIENCES
ARVARD
EDICAL
CHOOL
FAX
Grades and credit for rotations will not be assigned unless this form is submitted to your Program Coordinator.
Copies of this form may be obtained from your Program Coordinator.
FORM UPDATED 08/07

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