APPLICATION FOR OFF-SITE SUB-INTERNSHIP

University of Kansas School of Medicine

This application is for the specific use of receiving credit for the sub-internship rotation taken at another University or Medical Center. This application will REQUIRE that the following information is provided and turned in at least one month prior to the start date of the sub-internship.

1. Signature of Chairman or Course Coordinator from the KUMC like department
2. Signature of Assistant Dean for Student Affairs
3. A Course Description of the Sub-Internship

 TO BE COMPLETED BY THE STUDENT - PLEASE PRINT

Name of Student ______________________________________ KUID _______________ 

 Check one:

FAPR 901 - Family Medicine Sub-internship at non-KUMC location

GYN0 901 - OB/GYN Sub-internship at non-KUMC location

MED 908 - Medicine Sub-internship at non-KUMC location

OTOR 901 - Otolaryngology Sub-internship at non-KUMC location

PED 910 - Pediatrics Inpatient Sub-internship at non-KUMC location

PED 918 - Pediatrics Outpatient Sub-internship at non-KUMC location

PYCH 901 - Psychiatry Sub-internship at non-KUMC location

SURG 901 - Plastic Surgery Sub-internship at non-KUMC location

SURG 902 - General Surgery Sub-internship at non-KUMC location

SURG 909 - Neurosurgery Sub-internship at non-KUMC location

SURG 910 - Urology Sub-internship at non-KUMC location

SURG 915 - Orthopaedic Surgery Sub-internship at non-KUMC location

 Off-site Sub-Internship Information Required (please print):

Name of University / Medical Center ____________________________________

Address: __________________________________________________________
                 Department                            Room Number                               Street Address

Address: _________________________________________________________
                           City                                       State                                                    Zip Code

Phone Number: ________________________  Fax Number: _________________________

Instructor/Attending who will be evaluating your performance: ___________________________

Departmental Affiliation of Instructor/Attending named above: ___________________________

Date Sub-internship begins _______________    Date Sub-internship ends _______________

KUMC Department Approval

Approval is given for this student to take this course in fulfillment of their sub-internship requirement.  I have retained a copy for my records.

Name: _______________________________   Department:  ________________________

Signature __________________________________  Date:  __________________________

Return complete form to the Office of Student Affairs (3040 Murphy) to obtain SoM Student Affairs Approval.

____________________________________________
Laura L. Zeiger, Assistant Dean for Student Affairs

Date:___________________________

Last Modified: January 26, 2005
For more information contact: Laura Zeiger