Special Elective Request Form

Request Type*

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

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

Military

VSLO

Special Elective (All Other Request Types)

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

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

Yes

No

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.

Student First Name*

Student Last Name*

Student IU Email Address*

Student Status*

Third Year

Fourth Year

Inclusive Start Date*

Inclusive End Date*

Course Title (if any)

Discipline of Course Offering*

Select

Course Director First Name*

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

Course Director Last Name*

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

Course Director Credentials

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

Course Director Email*

Course Director Phone

Site Location*

Hospital name, clinic name, etc.

Site Address*

Address Line 2

City*

State*

Postal Code

Check here if the Proposal Contact is different from above

Elective Type/Category*

Evaluation Form Examples

PD - Professional Development

AS - Advanced Science/Research

CP - Clinical Practice

CE - Career Exploration

Is this a research elective?*

Yes

No

Student’s Expected Role in Project and Anticipated Work Product (e.g. analyze data from RedCap database using statistical methodologies, perform literature review, submit an abstract, etc.)

Course Description (from Course Director)*

Course Objectives (i.e. At the end of this rotation the student will be able to…)*

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

Duty Hours*

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

Why do you want to take this rotation?*

Please select all that apply

Interested in the specialty

Interested in host facility/residency program

Interested in working with a specific faculty member

Rotation unavailable in the IUSM electives catalog

Other

Course Director Approval*

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*

File Upload*

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

Drag and drop files here or

Are there any perceived conflicts of interest between the Course Director and Student (i.e. A health care provider who has provided care for a medical student or has a prior personal relationship)?

Please see the IUSM Non-Involvement of HC Providers in Student Assessment Policy for additional information.

Yes

No

Lead Advisor*

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

Select

Send me a copy of my responses