APPLICATION FOR SPECIAL ELECTIVE CONSIDERATION
8-weeks MINIMUM notice for all requests

IN ORDER TO BE CONSIDERED, ALL REQUESTS REQUIRE THE FOLLOWING:

STUDENT INFORMATION

DATE:

E-MAIL: 

NAME:

PHONE #:

SIGNATURE: 

PAGER #:

ELECTIVE INFORMATION

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?  
Nature of the elective and/or the place the elective will be completed. Check ALL that apply.

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 8/3/2016
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@drexelmed.edu