IN ORDER TO BE CONSIDERED, ALL REQUESTS REQUIRE THE FOLLOWING:
DATE: |
E-MAIL: |
NAME: |
PHONE #: |
SIGNATURE: |
PAGER #: |
TITLE OF PROPOSED ELECTIVE |
|
LOCATION OF PROPOSED ELECTIVE |
|
DATES OF ELECTIVE (inclusive) |
|
NUMBER OF PROPOSED WEEKS CREDIT |
|
Do you have any relatives/friends at this institution? |
An international medical school site. |
|
A non-medical school site that does not sponsor an approved elective. |
|
A medical school or affiliate rotation that is not an approved elective for that school. |
|
A research experience. Documentation of IRB approval or exemption must be inlcuded. |
|
Other (please explain)
|
COMMITTEE ACTION DATE: ____/____/____ |
|
|
APPROVED |
|
DENIED |
|
DECISION DEFERRED |
|
OTHER (specify) |
SIGNATURE OF CHAIR : |
Revised 01/28/2020
Special Elective Application materials are due the 1st Friday of each month to be considered at the monthly Special Elective Committee meeting which is held the 3rd Friday of the month. Applications received after the 1st Friday will be reviewed the following month. Decisions will be released the following week. Additional information may be requested following review. Allow at least 8 weeks advance notice for Special Elective Applications. Retroactive Credit will NOT be
granted -- please submit requests in advance.
Applications are to be submitted to Marcine
Townes in the Division of Clinical Education.
Return to Division of Clinical Education, 2900 Queen Lane, Room
114K, Philadelphia, PA, 19129; Fax# 215-843-7738 E-mail: clinicaleducation@drexel.edu