Elective Proposal Form

Elective Proposal Form

Elective Course Information

Elective Course Title*

Department/Discipline*

Select or enter value

Elective Course Director (First)*

Elective Course Director (Last)*

Elective Course Director (Credentials)

Email*

Phone*

Primary Elective Facility Address

Street Address

Address Line 2

City

State

ZIP Code

Campus/Region*

Select or enter value

Facility Location(s) of Elective

Please specify all sites that will be used for this rotation

Does the Course Director have a current faculty appointment?*

Yes

Please complete a personal profile form. Failure to submit an application for faculty appointment may result in declination or will delay the elective approval process.

Proposal Contact Name, if different from Above

Proposal Contact Email, if different from Above:

Name of Primary Contact for Adds/Drops (First)*

Name of Primary Contact for Adds/Drops (Last)*

Primary Contact Email Address*

Elective Course Description

Click each box below to see more information. Select your elective category in the following section.

AC - Advanced Clinical

Students will be exposed to a substantial load of patient encounters, with clinical experience in either the inpatient, procedural, or ambulatory setting. Students are expected to actively participate in the care decision discussions for the patients they encounter. Students will be integrated into the patient care team interactions, which may be any combination of physicians, residents, fellows, advanced practice providers, social workers, care managers, pharmacists, nursing, or practice staff under the supervision of the lead physician of the rotation. Students will discuss foundational science concepts as they relate to the diagnosis, treatment, and management of clinical disease states commonly encountered in the discipline with the supervising physician or care team. The elective will set clear expectations of the student’s role in the care environment at the start of the rotation and allow reflection time at the end, both from the student and the supervising physician, with attention to acquired skills that relate to the student’s preparedness for internship.

AS - Advanced Science

Designed to give each medical student the opportunity to pursue a personal scholarly experience in biomedical sciences (broadly defined) and to develop fundamental understanding in new areas of biomedical science relevant to clinical medicine. In these courses students will, after several years of clinical experience, revisit some aspects of basic science. Because of the level of sophistication that students have developed by this stage in their medical education, they can better understand the relevance of basic science to clinical problems.

CP - Clinical Practice

Students will become familiar with the fundamental principles of practicing in a particular specialty including diagnostic reasoning; evidence-based medicine; cost effective care; and self-directed learning. Further, students will learn to recognize manifestations of disease and manage the course of common illnesses found in the particular specialty. Finally, students will develop skills that address care of the healthy patient including preventive medicine; care of the patient with acute illness; and longitudinal care of the patient with chronic illness as well as care through the course of the complete illness/condition.

PD - Professional Development

Students will be exposed to the knowledge and skills outside the traditional medical school curriculum that will advance their success in medical practice.

CE - Career Exploration

Designed to allow Phase 2 students a beginning level immersion into a career of interest. Please note these electives are intended for Phase 2 (Third-year) students. Phase 3 (Fourth-year) students can apply only via a Special Elective form with special permission from their Lead Advisor and the Course Director.

Elective Type/Category*

Please select your Elective Category here

Is this elective in-person, online, or a hybrid course?*

On-site elective

Online elective

Hybrid elective (online and on-site)

Will students have patient contact in this elective?*

Yes

Brief elective course description*

Elective course activities*

Work hours per week*

Learning Objectives*

List specific and attainable learning objectives designed for this elective. Content should complete the following: By the end of this course, a student will be able to... (Tips for Writing Student Learning Objectives)

Assessments*

Describe the method(s) by which you will determine that the students have achieved the course objectives and by whom the assessment will be completed.(Examples may include observation, oral exam, written exam, logbook entries, case presentation, oral presentation, written essay, discussion with faculty, etc.). Include % allocation of each component and grade

Assessment Tools (Choose All that Apply)*

Clinical Practice & Advanced Clinical - Clinical Performance Evaluation Form

Professional Development Evaluation Form

Research Evaluation Form

Career Exploration Course Rubric

Other (Attach sample(s) of the assessment rubrics used in the elective)

Attach samples of assessment rubrics

Drag and drop files here or

Will your course participate in open enrollment (during the initial elective scheduling period) or does your course require permission prior to enrollment?*

Open Enrollment

Require Permission

Additional elective course information

(e.g., enrollment instructions not otherwise listed, housing provisions, off-site locations, or other special working conditions)

Additional faculty*

List additional faculty who will be working with students. If none, enter N/A

Will residents be teaching?*

Yes

If yes, what program are the residents from?

Prerequisites (Choose All that Apply)*

Third year status (Successful completion of second year)

Fourth year status (Successful completion of third year)

Clerkship prerequisite (Please specify):

Other (Please specify):

Clerkship prerequisites

Other prerequisites

Number of consecutive times a student may take this course:*

Note: Most electives will be 1 month in duration. Exceptions (e.g., research electives) will be considered for longer periods. Students may only re-enroll in Advanced Science Research electives. Students may re-enroll once in two-week electives for a total of four-weeks.

Duration:*

2-week

4-week

Longitudinal

Number of students per rotation

Number of students (maximum students per rotation) you will take at one time.

Fill in the blank with “0” (zero) if the elective is not offered that rotation. Please refer to the Phase 3 Rotation Schedule and Phase 2 Rotation Schedule for the rotation dates.

Rotation 1

Rotation 2

Rotation 3

Rotation 4

Rotation 5

Rotation 6

Rotation 7

Rotation 8

Rotation 9

Rotation 10

Rotation 11

Rotation 12

Longitudinal Elective Rotation Months & Duration

Please specify the length of time students will participate in this rotation (i..e. 3 months) and the rotation months during which this rotation is available (i.e. Students will complete this rotation over the course of 3 months. This rotation is available during Rotations 3-6 and Rotations 9-11).

Rotation 1A

Rotation 1B

Rotation 2A

Rotation 2B

Rotation 3A

Rotation 3B

Rotation 4A

Rotation 4B

Rotation 5A

Rotation 5B

Rotation 6A

Rotation 6B

Rotation 7A

Rotation 7B

Rotation 8A

Rotation 8B

Rotation 9A

Rotation 9B

Rotation 10A

Rotation 10B

Rotation 11A

Rotation 11B

Rotation 12A

Rotation 12B

Number of weeks a student must contact faculty prior to beginning elective:*

Estimated Time Distribution

Include the percentage of time a student will spend in each for the following categories. If none, enter 0.

% Clinical

% Laboratory or Scholarly Research

% Lecture/Seminar

% Library/Research

% Online

Does this course include service learning activities?

IUSM defines Service Learning as a structured learning experience that actively engages students, faculty, and community members in a dynamic partnership that intentionally connects community-identified concerns with institutional learning objectives. Each structured learning experience must have the following requirements: -Identified community partner and/or need -Pre-experience orientation -Service experience -Post-experience reflection.

Yes

Please describe.

Does this course include intentional opportunities for interprofessional collaboration?

Interprofessional collaborative experiences are opportunities for medical students to work collaboratively on health care teams that include students or practitioners from other health professions (e.g. dentistry, nursing, pharmacy, physical therapy, psychology, social work) as they provide coordinated services to patients.

Yes

Please describe.

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