Elective Proposal Form

Elective Course Information

Elective Course Title

Department/Discipline

Elective Course Director (First)

Elective Course Director (Last)

Elective Course Director (Credentials)

Phone

Primary Elective Facility Address

Street Address

Address Line 2

City

State

ZIP Code

Campus/Region

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

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

AS - Advanced Science

CP - Clinical Practice

PD - Professional Development

CE - Career Exploration

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)

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

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):

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 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

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

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