Request to take a Required Third Year Clerkship at a Non-KUMC Location

(Including Network Sites and Military Installations)

Students must complete all of their third year required clinical clerkships on the KUMC campus. Exceptions will be considered for those students requesting assignment at an established network rural site in Kansas. On rare occasions, students may obtain permission to complete a required clerkship at a military facility, if they are currently the recipient of a military scholarship.

This form must be completed in its entirety for each request. Original (not stamped) signatures must be obtained. The completed form must be returned to Laura Zeiger, Assistant Dean for Student Affairs, 3040 Murphy at least eight weeks prior to the start date of the clerkship.

Name _________________________________________ KU ID # _____________ Class _______

Required Clinical Clerkship ___ GYNO900: Obstetrics and Gynecology (6 wks) ___ PED900: Pediatrics (6 wks) ___ AMED900: Ambulatory Medicine/Geriatrics (6 wks) ___ FAPR950: Family Medicine (6 wks) ___ PYCH900: Neuropsychiatry (8 wks) ___ MED900: Medicine (8 wks) ___ SURG900: Surgery (8 wks)

Inclusive Dates of Rotation Begins: ________ Ends: __________ Dates at Network Site Location: From: ________ To: __________

SITE LOCATION:

___ Military Base________________________________________

Address (city/state/zip)____________________________________

Telephone Number where you can be reached _________________________

Evaluation should be sent to: ____________________________________

Address (if different from above)__________________________________

Evaluator’s Telephone Number _________ Evaluator’s Fax Number _______

___ Rural Network Site

FIRST CHOICE:

Network Address (city/state/zip)__________________________________

Telephone Number where you can be reached ________________________

Evaluation should be sent to: ____________________________________

Address (if different from above)_________________________________

Evaluator’s Telephone Number _________ Evaluator’s Fax Number __________

SECOND CHOICE (if first choice is unavailable):

Network Address (city/state/zip)____________________________________

Telephone Number where you can be reached __________________________

Evaluation should be sent to: ______________________________________

Address (if different from above)____________________________________

Evaluator’s Telephone Number __________ Evaluator’s Fax Number ________

_________________________________________________ Date: _________
Signature of student

Request Approved_________________________________Date: _________
Clinical Department Chairman or Clinical Course Director

Request Approved_________________________________Date:_________
Assistant Dean for Student Affairs or designee

Request Approved_________________________________Date: _________
Academic Committee Chair (required for Special Programs)

Request Approved _________________________________Date: ________
Associate Dean for Medical Education or designee (required for Network sites

cc: Medical Student Enrollment (3^rd floor Student Center)
Network Site Coordinator
Education Council Chair
Clerkship Director/Coordinator