Application Form Elective Type: Traditional (not Intensive Clinical or Basic Science) Name of Elective: Department: Faculty Responsible for Elective: Telephone Number: DESCRIPTION OF COURSE ACTIVITIES AND LOGISTICS: Please provide a concise but complete description of the course activities and experiences in which students will engage during this elective course. Include performance expectations and any necessary logistical details. STUDENT LEVEL: Is this course appropriate for Year Three students if prerequisites listed below are met? Yes, include this course in the Year Three Elective Catalog (maximum course length for Year Three students is 2 weeks). No, this course is appropriate ONLY for students who have successfully completed ALL Year Three Clerkships. E-mail Address: OBJECTIVES: Please list the specific and attainable learning objectives designed for this elective. EVALUATION: Please describe the method(s) by which you will determine that the student has achieved the course objectives (observation, oral exam, written exam, logbook entries, case presentation, oral presentation, written essay, discussion with faculty, etc.). NOTE: If there is a clinical component in this elective, students are required to maintain a logbook of patient encounters. ADDITIONAL FACULTY INVOLVED: PREREQUISITES: PREREQUISITES: Successful completion of all third-year clerkships.Successful completion of the following clerkship(s) OR Other (please specify) Enter other… (mark all of the following that apply) NOTIFICATION REQUIREMENT: 2 Weeks 3 Weeks 4 Weeks Other… Enter other… Most faculty ask students to make contact in advance of the course start date. This is a good safety net for faculty and students to ensure everyone is prepared for the elective experience. Please indicate how far in advance you would prefer that students contact you or your designee. Contact Information (If other than responsible faculty) Name, Phone, Email Training? MMC SJH SIU (TouchWorks) This course will require computer training at:
