OMS IV Away Rotation Request Form – Burrell College of Osteopathic Medicine Forms

Name*

First Last

Email*

Please always use your Burrell College of Osteopathic Medicine Email (ex firstname.lastname@burrell.edu )

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

Hidden

Date Submitted:

Rotation Specialty:*

Select One:*

Selective ICU
Selective Sub-I
Selective Emergency Medicine
N/A

Indicate Selective:*

NICU/PICU
ICU/Critical Care

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:*

Fax:*

Preceptor Name:*

First Last

Preceptor Email:*

Hidden

Preceptor Medical License Number:

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:*

Fax:*

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. Preceptors must be credentialed and both the Institution and Burrell College of Osteopathic Medicine must 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.