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Fields
Laboratory Rotation Agreement - Student
Student Name
*
First Name
*
Last Name
*
Student Email Address
*
Life Number
*
Degree
*
PhD Student
MD / PhD Student
MTA
PTD
CAB
DRS
GDS
IMM
MIC
NEU
Lab Rotation #
1
2
3
4
5
Rotation Preceptor Name
*
First Name
*
Last Name
*
Rotation Preceptor Email
*
Rotation Start Date
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Rotation End Date
*
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Laboratory Rotation Agreement - Rotation Preceptor
Who will directly supervise the student?
First Name
Last Name
Hours per week that a student is expected to be in the laboratory:
*
Laboratory activities expected of the student:
*
Select
*
Were laboratory guidelines/policies (e.g., biohazards, lab notebook) explained to the student?
Has the student been provided with a reading list?
Is the student expected to attend lab meetings?
Will the student be required to present in a lab meeting before the end of the rotation?
Does the student have to participate in departmental seminars?
Goals for this rotation:
*
Has the student met with his/her first year advisor?
*
Yes
No
Other:
Other Value
At the end of this rotation the student will meet with the rotation preceptor and complete the Laboratory Rotation Evaluation Form BY SIGNATURE, I VERIFY THAT I HAVE DISCUSSED THE LIKELIHOOD OF MY HAVING SPACE AND FINANCIAL SUPPORT, SHOULD THIS STUDENT AND I WISH TO CONSIDER A THESIS DEVELOPMENT AFTER THE ROTATION PERIOD.
*
Yes, (If the rotation works out, I will be able to accept this student into my laboratory in July)
Very likely (If the rotation works out, I will very likely be able to accept this student into my laboratory in July)
Possibly (If the rotation works out, I will possibly be able to accept this student into my laboratory in July
No (I will not be able to accept this student in July)
Yes, Student is eligible for NIH Diversity Supplement http://icahn.mssm.edu/diversitysupplements
No, Student is not eligible for NIH Diversity Supplement http://icahn.mssm.edu/diversitysupplements
Rotation Preceptor Signature
*
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Use your mouse or finger to draw your signature above
Student Approval
Approve
*
Yes
Signature
[clear]
Use your mouse or finger to draw your signature above
Graduate School Office Approval
Approve
*
Yes
Signature
[clear]
Use your mouse or finger to draw your signature above
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