INTERDISCIPLINARY SPECIAL PROGRAM : IDSP-800¹

School of Medicine, University of Kansas Medical Center

All information is required:

KUMC STUDENT:______________________________________STUDENT NO. ____________________

AVAILABLE DAY PHONE:______________________________E-MAIL ADDRESS: ___________________

Summer ADDRESS while doing elective:

_____________________________________________________________________________________

TIME: # Weeks doing elective at the site:___________; From m:____/d:____ TO m:____/d:____

P: Full Time (40hr/wk) _______ Part Time (≤20hr/wk) _______ Credit Hours Proposed: _______

ELECTIVE TITLE: ________________________________________________________________________

Involves student's contact with patients: YES ______ NO ______

MENTOR:_____________________________________________DEGREE: __________________________

TITLE:_______________________________________________________PHONE: ____________________

EMAIL:_______________________________________________________FAX: ______________________

ADDRESS (nclude Hospital Name/Address if applicable)

If KUMC, indicate only Department Name _________________________Office Location:________________

_____________________________________________________________________________________

CITY: __________________________________________________STATE ________ ZIP _____________

Agree to submit Student Performance Evaluation at completion (will be e-mailed): YES ______ NO ______

EXPAND & CONTINUE ON ANOTHER PAGE AS NEEDED:

1. Educational Objectives?

2. Description of plan(s) to achieve the objectives:

3. STUDENT PARTICIPATION - List activities the student will do and skills to be enhanced or learned.

4. PRIMARY MENTOR(S) - name(s) /title(s) who will have significant training contact with student?

¹Mentor: Please Fax (913-588-5242) or E-mail (jbast@kumc.edu) Proposal to J.D. Bast, Assoc. Dean, Graduate Studies

idsp-800 elective clinical proposal e-format