Banner

Non-Established Elective / Sub-I Application

Before you begin your application have the following information available:

IMPORTANT: To receive credit and to be covered by liability insurance your application must be submitted 4 weeks before the start date of the elective or sub-internship. Credit will not be awarded for electives or sub-internships taken prior to submission and approval of this application. When completing the application have all information available as you cannot save a partially filled application and complete it at a later date. Incomplete applications will not be reviewed for approval.

For information regarding late fees for Non-Established Electives and Sub-Internships go to Geisel Registrar.

Directions:

  1. Complete Sections 1 through 5 of application.
    Please do not provide email addresses such as gmail, hotmail, outlook.com, yahoo.com, etc. These systems are not permitted in OASIS as the data is protected by FERPA laws and Dartmouth policies prohibit their use for work with student information.
  2. Submit application. The Registrar's Office will send you an email after your application has been reviewed.

Entries marked with * are required.

Section 1: Student and Elective/Sub-Internship Information

First Name*:

Middle:

Last*:

Class Year*:



Graduation Year*:

Email Address*:

Do not provide email addresses such as gmail, hotmail, yahoo.com, etc. See instructions above.

Phone Number:

Start date of Elective/Sub-Internship*:

Calendar

End date*:

Calendar

Number of weeks*:

Number of credits*:

1 credit = one 40 hour week

Elective/Sub-Internship Name*:

The Registrarís Office will determine the final name of the elective/sub-internship

Is this an established elective or sub-internship at the host institution*:



i.e. is the elective/sub-i listed in their course catalog

Rotation Type*:




Is this an International Elective/Sub-Internship*:



If 'Yes', you MUST complete the International Release Form and upload with this application:

allowed file types: .doc, .pdf

Section 2: Faculty Sponsor Information

Faculty Sponsor Name*:

First and Last Name

Faculty Sponsor Email Address*:

Do not provide email addresses such as gmail, hotmail, yahoo.com, etc. See instructions above.

Site Location*:

Affiliated Medical School*:

Enter N/A if this site is not affiliated with a medical school

Department*:

Address Line 1*:

Address Line 2:

City*:

State*:

Zip*:

Telephone*:

format XXX-XXX-XXXX

Fax:

Program/Department Coordinator Name:

Coordinator Email Address:

Do not provide email addresses such as gmail, hotmail, yahoo.com, etc. See instructions above.

Section 3: Approval from VSAS, Faculty Sponsor, or Institution

Approval documentation is required. Select the type of approval then upload your VSAS confirmation or approval letter/email from the faculty sponsor or institution.

Type of Approval*:



Upload Approval VSAS Confirmation or Letter/Email*:

allowed file types: .doc, .pdf

Section 4: Student Performance Evaluation

Name of Evaluation Recipient*:

Evaluation Recipient Email Address*:

Do not provide email addresses such as gmail, hotmail, yahoo.com, etc. See instructions above.

Section 5: Detailed Non-Established Elective/Sub-Internship Information

In order to obtain approval for your elective, you must provide all the information as described in A through D. Do not upload a document in place of completing A-D. In addition, you may upload the course information provided by your faculty sponsor or host institution as supplemental information.

Tip: In general, you should work with your sponsor to develop the following information. Electives and sub-internships taken at other institutions may provide you with all the required information (see A-D below) on their website. Your application will not be reviewed/approved if the information you provide is incomplete.

A-D: Elective/Sub-Internship Detailed Course Information
You may cut and paste information into the text boxes provided for A-D.

A) Course Description*:

Provide a brief overview of the content and structure of the elective/sub-internship

B) Course Learning Objectives*:

List the learning objectives provided by the course director or develop specific learning objectives with your sponsor if this is a new elective

C) Methods of Student Instruction*:

Explain the learning environments/tools to be used (e.g. Clinic and ward activity, grand rounds, case conferences, directed reading)

D) Methods of Student Evaluation*:

Indicate the methods by which you will be evaluated (e.g. direct observation of clinical performance, simulation, written test, final paper, formal case presentations)

Indicate which of the following your evaluator will submit to the Geisel Registrar*:



Additional Information: