Application for Elective Rotation

This application must be completed and received two months prior to the proposed starting date of the rotation. Failure to meet this deadline may result in an assigned rotation or other option by the Office of Clinical Education.

Note: All fields marked with a * below are required. All other fields are optional.

User Information

First Name

Last Name

Phone

Address

Street

Apt/Suite/Etc.

City/Town

State

Zip/Postal Code

Graduating Class Year

Core Hospital Track

Rotation Information

Rotation Type

SpecialtyPlease choose the specialty and then sub-specialty if applicable

Rotation Start Date

Rotation End Date

Submitted through VSAS or Clinician Nexus

Site Information

Site Name Specific name of Hospital/Clinic/Drs. Office

Type

Institutional: Rotation completed at a hospital or through a residency program

Non-Institutional: Rotation completed outside of hospital, not affiliated with a residency program

Is an affiliation agreement required for this rotation?

Yes

Address

Street

Apt/Suite/Etc.

City/Town

State

Zip/Postal Code

Supervising Physician/Preceptor

Preceptor must be board certified in the discipline selected and licensed as a DO or MD.

First Name

Last Name

Credentials

Phone

Site Coordinator

Full Name

Phone

Notes/Comments

Proof of Acceptance by Rotation Site (e.g. email confirmation, screen shot of VSAS or Clinician Nexus acceptance, etc.)

Proof of Payment (Only for rotations requiring payment)

Letter of Cancellation If this application is replacing a current scheduled elective please upload a letter of cancellation

Request for Affiliation Agreement Please submit only if requested by rotation site

Application for Elective Rotation

User Information

Rotation Information

Site Information

Program Director

Supervising Physician/Preceptor

Site Coordinator