The University of Kansas School of Medicine-Wichita
Application for Special Program
(off-site LCME Accredited educational experience)
Description:
A “Special Program” is any scholastic activity that departs from the required, selective, or elective curriculum at The University of Kansas School of Medicine, Wichita or Kansas City campus, for which the student expects to receive credit. Student may receive no more than 8 units (wks) of off-site credit counting toward the M.D. degree. Any currently enrolled KU medical student is eligible to apply. (This is not the appropriate application for an international elective experience.)Elective enrollment must be through an LCME accredited Medical School program with medical school faculty.You will receive elective credit for this course and be enrolled in SPCP 976, Special Program.
Where to start:
Please contact the possible host medical school(s) and finalize where/when you will do your rotation before you complete the KUSM-W application.
Host Medical School Requirements:
The host institution will most likely have an application process for you to complete, which may include the VSAS on-line process. If not a VSAS application, they may request that KUSM-W verify information such as malpractice insurance, USMLE status, enrollment status, etc. Academic & Student Affairs will either complete the host institution’s application form and/or write a letter in support of your application. Please submit their application form or let us know what information needs to be included in a letter and the name and address of the person/institution to address everything to. Immunization records: we can print out or send you an electronic copy of your KU immunization records, or our Student Health staff can complete/sign the host school’s own form (depending on the host school’s requirements).
KUSM-W Requirements:
This course is designed for fourth year students. All applications and support materials must be completed and submitted to the office of Academic & Student Affairs at least two months prior to the expected starting date of the rotation. The student is responsible for collecting and submitting all application materials to Academic & Student Affairs. All application materials must be submitted and approvedbefore beginning date of off-site experience. Application includes:
- Completion of parts A, B, C, D of the form (Student will send Part D to host school for completion and return to ASA)
- A written course description from the host school (may be found online)
Completing the Application Sections:
-Part A: If the host school has not yet notified you as to which course/faculty you will be enrolled for, let us know later. Hopefully, the host school course dates are the same as ours (appropriate dates available in ASA or online). “Location of Program” is the site where the rotation is offered. “LCME Med School Name” may be the same as the program or it may be the umbrella school, which the program is affiliated with (address is for the school). If you do not know your supervisor/evaluator, it will be on Part D when it is completed and returned to us. The contact person is the one in the academic office you are working with to complete your application at the host school (also, if I need to contact you while you are there, or retrieve your final grade). You must sign/date this form before you submit it to us.
-Part B: Take the completed application and course description to the KUSM-W department under which your away elective would fall, for their approval/signature.
-Part C: Submit your completed application and course description (completed/approved by the KUSM-W department) to Academic & Student Affairs for final approval.
-Part D: Send this page to the host school for them to complete and return to Academic & Student Affairs, KUSM-W. The completed Part D can be returned to us via FAX (316-293-1851), mail, or e-mail (this is usually the most time consuming portion of the application, so send this off as soon as you have been approved at a specific institution).
***We want your feedback about your experience on this elective. You will receive an evaluation form for you to complete at the end of this elective. Please complete and return it as soon as possible. If you have a negative experience from this elective, please notify someone in ASA.
For additional information e-mail or call 293-2603.
The University of Kansas School of Medicine-Wichita
Application for Special Program @ LCME accredited Medical School
I hereby request permission to receive academic credit toward the M.D. degree for the special program course outlined on this application and accompanying support materials (attach course description). I understand this application will not be approved if the elective is not through an LCME accredited medical school.
Student Name:
(please type or print legibly)
Part A: Student Course Request
Course Name: Course Dates:
Location of Program: Number of Weeks:
LCME Med School Name:
Address:
Street City State Zip
Supervisor/Evaluator Name: Title:
Contact Person Name: Phone:
E-Mail: FAX:
Contact Info while at away site:
Phone:
Student’s Signature: Date:
Part B: KU School of Medicine-Wichita Clinical Department Approval (department corresponding to requested elective)
The Department of approves this special program application.
Signature of Chairman or designee: Date:
Part C: KU School of Medicine-Wichita Associate Dean Approval
The Associate Dean for Academic & Student Affairs approves this special program application.
Signature of Associate Dean: Date:
KUSM-W Course Number: Line Number: Credits:
The University of Kansas School of Medicine-Wichita
Academic & Student Affairs
1010 North Kansas
Wichita, KS 67214
Phone: 316-293-2603
FAX: 316-293-1851
APPLICATION FOR SPECIAL PROGRAM @ LCME ACCREDITED MED SCHOOL
Student: Please complete the top portion and send this page of your application to the host school for completion of the bottom portion.
Student’s Name:
Approved Course Name: Dates:
Host Med School Name:
Application is through VSAS _____ Application is through Host School _____
Part D: Host Institution Supervisor/Evaluator Verification
Dear Host Institution:
Thank you for accepting our medical student as a visiting student at your institution. Part of our application process includes identifying the member of your faculty who will supervise and evaluate our student. The medical student’s application is not complete and cannot be approved until we have received this completed form. The University of Kansas School of Medicine students are not covered by malpractice insurance unlessthey are enrolled in an LCME accredited Medical School, approved course, so it is imperative that we receive this form in our office before the beginning of the rotation. Please have the appropriate staff member complete this form and return prior to the beginning date indicated below, mail, e-mail, or FAX to:
Melanie A. Runge, Coordinator e-mail:
Academic & Student Affairs FAX: 316-293-1851
University of Kansas School of Medicine-Wichita
1010 North Kansas
Wichita, KS 67214
Please type or print legibly
Host site contact person for final grade: Phone:
Name and Title of School Faculty Supervisor/Evaluatorat LCME Host School:
School faculty listed above will supervise and evaluate this visiting medical student’s performance on his/her rotation as listed above.
Signer Name: Title: Date:
Signature: Date: