Please Contact the Office of Education, 732-235-5006, for a Word Version of This Form

Fourth Year Elective

Please contact the Office of Education, 732-235-5006, for a Word version of this form.

This form is only to be used by an elective director when establishing a new elective. Please be sure to fill this form out completely and include your signature before forwarding it to the Department Chair. This form must include all required signatures. Upon completion, please forward this form to the Office of Education, Rutgers-RWJMS, 675 Hoes Lane, Rm. TC-116, Piscataway, NJ 08854

Fourth Year Elective Title / Course Number
Leave blank – Registrar will provide # / Location
Elective Director / Elective Faculty / Elective Contact / Contact Info
Ph.
Fax
Email:
Blocks Available / Duration/Weeks
Min: Max: / Hours per Week / Students
Max:
Lectures/Seminars
Yes or No / Outpatient
Yes (___%) or No / Inpatient
Yes or No / Housestaff
Yes or No
Night Call
Yes or No / Weekends
Yes or No / Lab
Yes or No / Exam Required
Yes or No

Overall Educational Goal of Elective

Objectives

I. Patient care

II. Medical knowledge

III. Practice-based learning and improvement

IV. Interpersonal and communication skills

V. Professionalism

VI. Systems-based Practice

Brief Description of Activities

Method of Student Evaluation

Are there any prerequisites for this elective? No Yes , please specify

Is this elective available to third year medical students as well? No Yes

APPROVALS:

Required Signatures:

ELECTIVE DIRECTOR:

print name signature:

DEPARTMENT CHAIR or DESIGNEE:

print name signature:

APPROVED BYCURRICULUM COMMITTEE:

date