| OUT OF
TOWN ELECTIVE FORM
Instructions:
Once complete, please submit to the Office of Medical Education, BEB 40.
|
| ___________________________________________________ |
__________________________ |
| Student's Name |
Month Away |
| ___________________________________________________ |
__________________________ |
| Out of Town Institution |
Department |
| _______________________________________________________________________________ |
| Address |
| _______________________________________________________________________________ |
| Course and
Instructor |
| ___________________________________________________ |
__________________________ |
| Approved by Departmental
Course Coordinator |
Date |
| ___________________________________________________ |
__________________________ |
| Approved by OME |
Date |
