SPECIAL ELECTIVE REQUEST: Application

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

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

A completed application for Special Elective consideration
A cover letter from the student explaining the request and outlining the educational objectives the student wishes to achieve from the rotation. This must be signed by the student.
A description of the elective signed by the course director. This should include a weekly grid of activities. For research, include specific goals and objectives consistent with the length of the rotation/experience signed by the principal investigator. (Do not submit formal grant proposal). Attach IRB approval or exemption. See Research Example.
Letter from away school or site indicating acceptance for rotation and specifying dates signed by the away site.
An Approval of the Pathway Director/advisor (specific form).
A copy of the Student's 4^th year schedule (please complete form) Do not provide printed schedule
If application for international elective, signed DUCOM Statement of Responsibility and Legal Release must be included

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