Individually Designed Elective

Due 60 days prior to start of the elective

Student Name / Banner ID
Student Phone / Year
Student Pager
Student Address
Student Email / @students.ecu.edu
Elective Title
Preceptor& Email / Email:
REQUIRED for evaluation
Licensure #
(if not ECU faculty)
Name of Practice or Hospital
Address/Location of Elective
Street Address/PO Box
City/State/Zip
Telephone / Fax
Meeting Time (where and when to report on 1st day of rotation)
Date / State Date: / Finish Date:
Duration (check one) / ______2 weeks / ______4 weeks
Overall Course Goal
Educational Objectives (min of 3) / 1.
2.
3.
Readings/ Course Literature / The following materials will be used- assignments will be as individualized.
Activities/Students Experience / Describe the course activities:
  • Lectures, clinics, conferences to be attended?
  • In what location will students be observed on this elective?
  • How will students receive mid-course, formative feedback of their performance?
  • Oral presentation, written assignments required?
  • Research requirement?
Describe on call requirements, if applicable (including specific duty hours):
Other Requirements / Please provide any other pertinent information below:
Evaluation / Describe how student performance will be assessed and how the course grade will be determined:
  • I certify that this elective will be directed by the identified Preceptor, who is member of the faculty of the Brody School of Medicine or a licensed physician or doctoral level instructor who has been approved to direct this elective. I also certify that the department will provide the needed resources to conduct this electiveduring the rotation blocks shown.

______Date______

Preceptor’s Signature

  • I certify that I will be supervised by a licensed physician or doctoral level instructor who is not an immediate family member.

______Date______

Student’s Signature

Please return to:The Brody School of Medicine at East Carolina University

Office of Student Affairs, Brody 2S-20

Greenville, NC 27834

Telephone: (252) 744-2278 Fax: (252) 744-3250

Office Use Only:

This Elective will meet the following requirement: (Check all that apply)

Primary Care Elective ______Acting Internship Elective______Miscellaneous Elective______

M4 Curriculum Chair/Subcommittee Approval: ______Date______

(Signature)

Official format approved by ECC 12/2017