Special Elective Request Form

Please be sure to review the information on the Special Electives page prior to completing this form.

 

See the Special Electives page for a description of each request type:

https://medicine.iu.edu/mse/education/electives/special-electives

 

Is the start of this special elective at least 30 days from now?

 

Per school policy, the completed form and supporting documentation must be submitted a minimum of 30 days prior to the start of the rotation to receive IUSM approval and credit for the rotation.

 

 
 
 
 
 
 

 
 
mm/dd/yyyy
 
 
 
 

The Course Director must be a faculty/physician who will be supervising the student during the rotation

 

The Course Director must be a faculty/physician who will be supervising the student during the rotation

 

M.D., D.O., Ph.D.., etc.

 
 
 

 
 

Hospital name, clinic name, etc.

 
 
 
 
 
 

 
 
 
 
 
 
 
 

For guidance on how to write learning objectives, please consult the Writing and Assessing Student Learning Outcomes resource.

 
 

(include days/times & avg. hours/week)

 

Please select all that apply

 

 

By checking this box: "I affirm that I have received approval for this special elective from the course director prior to the submission of this request."

 

 

Course Director Approval Attachment

Proof of approval must be uploaded (i.e. email, etc.,). Use the file upload below*

 

Additional Assessment Methods (Rubrics/Assessments other than the standard form)

Please see the standard evaluation form for this elective type linked above under "Elective Type/Category". Please use the file upload below*

 


Accepted file types: pdf, docx, xls, doc, xlsx, jpg, png, gif, Max. file size: 30 MB

Drop your files here
 

 
 

 

Please select your lead advisor from the list below so that this request can route to them for approval.

 

 

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