Clinical Tailor-Made Elective Proposal & Registration

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Registration for Clinical Tailor-Made Elective

DIRECTIONS

Download the Clinical Tailor Made Elective Mentor/Mentee Form. You must have this form signed and completed by your mentor before filling out this form.
Develop the elective together with your mentor.
Meet with your mentor to discuss the elective plan, time frame, expectations, and the Mentor/Mentee form.
Upload Mentor/Mentee Agreement Form to this form.
Submit this form at least 2 weeks prior to the anticipated start date of the elective.
Form will be reviewed by the Director of Medical Student Electives for approval. If they have any questions, they will reach out to the student.
Once approved by the Director of Medical Student Electives, the form will be routed to the Office of the Registrar for final approval.
Students must wait until they receive an email notification that the Clinical Tailor-Made Elective proposal has been approved. The approved elective will also appear in Empower in the Student Schedule (Summary) area at student.mssm.edu.
After your elective ends: It is your responsibility to make sure that your elective is graded. Complete the student portion of the Elective Grade/Evaluation Form at the end of your rotation which will be automatically emailed to the evaluator email you submit.

Student Information

STUDENT NAME*

First Name

Initial (optional)

Last Name

LIFE NUMBER*

SCHOOL EMAIL ADDRESS*

PERSONAL EMAIL ADDRESS

CELL PHONE

CLASS YEAR*

What is your projected graduation year

DETAILS OF CLINICAL TAILOR-MADE ELECTIVE PROPOSAL

Please select the academic year you will be taking this elective. *

2023-2024 2024-2025

ELECTIVE TITLE (as it will appear on your transcript)*

100 character limit

ELECTIVE TITLE: Please select the specialty that most identifies with your elective. The title of your elective will be "Clinical Elective: Specialty" *

Is this a split elective?

Yes No

ELECTIVE START DATE*

ELECTIVE END DATE*

ELECTIVE 2nd START DATE

ELECTIVE 2nd END DATE

HOURS PER WEEK*

List in numerical value the amount of hours per week you will be spending on this elective

TOTAL NUMBER OF WEEKS*

List in numerical value the total number of weeks you will be spending on this elective

GOALS & OBJECTIVES

List 3 goals/objectives aligned with the proposed elective

#1 - GOALS/OBJECTIVES OF THE ELECTIVE *

1 OF 3

#2 - GOALS/OBJECTIVES OF THE ELECTIVE*

2 OF 3

#3 - GOALS/OBJECTIVES OF THE ELECTIVE *

3 OF 3

DESCRIPTION OF THE ELECTIVE

Please describe the details of the elective, including how this will be an active learning experience (e.g. - through participation in case conferences, presentation of patients to preceptor, etc.).

Also include the following areas in the description:

Main focus of the elective
Primary setting/location
Level of supervision involved (indirect/direct) and who will be supervising
Level of patient contact (if applicable)
Responsibilities of the student

DESCRIPTION OF THE ELECTIVE*

Describe the elective using the parameters above

MENTOR INFORMATION

NAME OF MENTOR*

First Name

Last Name

EMAIL OF MENTOR*

DEPARTMENT OF MENTOR*

TELEPHONE OF MENTOR

Optional

Student Comments:

Optional

Upload Mentor/Mentee Agreement Form*

No File Chosen

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By signing below you are confirming all information is accurate and you are not scheduled for another elective or required rotation during the dates you are requesting.

STUDENT SIGNATURE*

[clear]

Use your mouse or finger to draw your signature above

TODAY'S DATE / TIME *

Signed by student

Director of Medical Student Electives

APPROVAL STATUS - DIRECTOR OF MEDICAL STUDENT ELECTIVES*

Approve Deny

REVIEW DATE - DIRECTOR OF MEDICAL STUDENT ELECTIVES*

COMMENTS - DIRECTOR OF ELECTIVES:

Office of Registrar

APPROVAL STATUS - OFFICE OF THE REGISTRAR*

Approve Deny

REVIEW DATE - OFFICE OF THE REGISTRAR *

COMMENTS - OFFICE OF THE REGISTRAR

From Office of the Registrar

Do the start or end date need to be revised?*

Yes No

Final Elective Start Date*

Final Elective End Date*