Application Form

Elective Type:  Traditional (not Intensive Clinical or Basic Science)


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?
Please list the specific and attainable learning objectives designed for this elective.
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.
(mark all of the following that apply)
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
This course will require computer training at: