SPECIAL ELECTIVE: REQUEST FOR SENIOR CREDIT, FUNDED RESEARCH FELLOWSHIP

All necessary materials needed for a special elective request must accompany this application.Requests will not be considered unless all materials are submitted.

Name

Class

Mail Box

Phone

Pager

E-Mail

Title of Research Project

 

Location where Project Completed

 

Year in which doing research? 3 or 4

 

Please check.

NMF Fellowship Program in Academic Medicine Ė Bristol-Myers Squib Co.

 

NMF Fellowship in Academic Medicine Ė W.K. Kellogg Co.

 

Other Fellowship: Please specify name.

 

Time required out of standard curriculum for participation in the fellowship.

Length of time required from the 3rd year

 

Length of time required from the 4th year

 

Names of any 3rd year rotations deferred for the research fellowship.

 

 

Weeks of Senior Credit Requested

 


In order to be considered, requests require the following:

1.        Cover letter from the student explaining the request and outlining the educational objectives the student wishes to achieve during the research fellowship.

2.        A description of the research project, the research proposal, and/or the plan by which the fellowship specifies development and completion of the research project.

3.        If a third-year student, signature of approval from a faculty or administrative advisor.

4.        If a third-year student, the studentís third year schedule.

5.        For both third and fourth year students, include in the schedule the proposed length of time devoted to the fellowship.

6.        If a fourth year student, signature of approval of the Pathway Director/Advisor.

7.        If a fourth year student, the studentís fourth year schedule.


Return all materials with the completed Special Electives Request Packet to the Division of Clinical Education.Seniors: Must submit before end of Block 6.


COMMITTEE ACTION

DATE

††††††††††††††† APPROVED

 

WEEKS OF CREDIT

 

††††††††††††††† DENIED

 

††††††††††††††† DECISION DEFERRED

 

††††††††††††††† OTHER (Specify)

 

Chairís signature


Return to Division of Clinical Education

2900 Queen Lane, Philadelphia, PA19129

Fax(215) 843-7738