OMS III Away Elective Request Form – Burrell College of Osteopathic Medicine Forms

Name*

First Last

Email*

Enter Email Confirm Email

Does Program Use:*

VSLO/VSAS
ClinicianNexus
Audition/GME
Student Initiated Elective

Is the Rotation Start Date at least 60+ days away?*

Yes
No

Please contact clinicaleducation@burrell.edu

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Date Submitted:

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Location:*

Away
In Hub

Hub:*

Rotation Specialty:*

Albuquerque Rotation Specialty I:*

Albuquerque Rotation Specialty II:*

Albuquerque Rotation Specialty III:*

Eastern NM Rotation Specialty I:*

Eastern NM Rotation Specialty II:*

Eastern NM Rotation Specialty III:*

El Paso Rotation Specialty I:*

El Paso Rotation Specialty II:*

El Paso Rotation Specialty III:*

Las Cruces Rotation Specialty I:*

Las Cruces Rotation Specialty II:*

Las Cruces Rotation Specialty III:*

Tucson Rotation Specialty I:*

Tucson Rotation Specialty II:*

Tucson Rotation Specialty III:*

Requested Dates for Rotation:

Rotation Start Date:*

Rotation End Date:*

Rotation Site / Institution

Name:*

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Phone:*

Preceptor Name:*

First Last

Preceptor Email:*

Do Clinics or Hospitals the Preceptor practices/rounds at need an Affiliation Agreement?*

Yes
No

Proof of Affiliation Agreement Status:*

Note: It is the student’s responsibility to ask the preceptor/facility if an Affiliation Agreement is required on their end. Please upload a screen capture of your communication with the facility stating if an Agreement is required or not.

Drop files here or

Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx, Max. file size: 8 MB.

Hospital/Clinic Name:*

Hospital/Clinic Contact Name:*

First Last

Hospital/Clinic Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hospital/Clinic Email:*

Hospital/Clinic Phone:*

Office Manager / Site Coordinator

Manager / Coordinator Name:*

First Last

Email:*

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Phone:*

Preceptor CV:*

Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx, Max. file size: 8 MB.

Preceptor Malpractice:*

Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx, Max. file size: 8 MB.

Proof of Audition/GME Confirmation:*

Drop files here or

Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx, Max. file size: 8 MB.

Please upload a screen capture of proof that this rotation is an audition or is held at a GME facility. In order to receive credit for the rotation, you will need to submit your preceptor’s CV and malpractice insurance once they are assigned.

Note: Student will be given some responsibility to assist in paperwork necessary for credentialing of their preceptors and establishing affiliation agreements if that facility requires an AA.. Preceptors must be approved. Both the Institution and Burrell College of Osteopathic Medicine execute agreements no less than ninety (90) days prior to the anticipated rotation start date, or the rotation may be cancelled.

Proof of Confirmation:*

Drop files here or

Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx, Max. file size: 8 MB.

Examples include a screen capture of communication from facility or preceptor accepting you for the rotation dates requested.

Student Signature:*

Date*

Submission of this request form does not constitute approval.