GUTHRIE: VISITING MEDICAL STUDENT AND INTERNATIONAL MEDICAL GRAUDATE ROTATION REQUEST FORM

GUTHRIE: VISITING MEDICAL STUDENT AND INTERNATIONAL MEDICAL GRAUDATE ROTATION REQUEST FORM

Welcome to Guthrie's Medical Education Department. This form is to be used by International Medical School Graudates, non-GCSOM and LECOM Longitudinal M3 and M4 students to request rotations at Guthrie.

Date of this Request:*

Student's Last Name:*

Please enter your last name:

Student's First Name:*

Please enter your last name.

Student's Email Address:*

Student's Phone Number:*

Name of School/Program:*

Please provide the name of your medical school.

Select or enter value

Educational Affiliate's Contact Email Address

Medical Students, please provide the school's placement contact person's email address.

IMG ONLY: NAME OF SPONSOR

International Medical Graduates should enter their sponsoring Guthrie Provider's NAME.

TRAINING LEVEL:*

Please use the drop down menu to select your training level.

Select

ROTATION SPECIALTY:*

Please use the drop down menu to identify the specialty of the requested rotation.

Select

CURRICULUM REQUIRES OPERATING ROOM EXPERIENCE?*

Please use the drop down menu to indicate if an OR experience is required as part of this rotation.

Select

IF OR EXPERIENCE REQUIRED - TYPE?*

Please use the drop down menu to identify the curriculum required type of OR experience.

Select

Rotation Site:*

Please identify the Guthrie entity for this rotation.

Select

Specific Site:

Please provide any additional information about the specific rotation site such as "Southern Tier Pediatrics."

Requested Rotation Start Date:*

Requested Rotation End Data:*

GUTHRIE PRECEPTOR'S NAME:*

If you have already consulted with a Guthrie physician for precepting, please provide their name and email address.

Preceptor's Email Address:*

Provide this email address if you have already consulted with a Guthrie physician for precepting your rotaiton.

COVID VACCINATION STATUS:*

Please identify your current vaccination status.

Select

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