UVM Larner College of Medicine Clerkship Site Exemption Request Form
The UVM LCOM curriculum offers clinical opportunities at the UVM Health Network and affiliate sites which include the Western Connecticut Health Network, in Danbury and/or Norwalk, CT; at Hudson Headwaters Health Network in Glens Falls, NY; and at St. Mary’s Medical Center, in West Palm Beach, FL.
Students may be eligible for a clerkship site exemption if they meet the criteria listed below. Please note that the options for applicable grounds that follow are the only options that UVM LCOM can take into consideration. UVM LCOM is unable to make exemptions for pet ownership or other situations not listed below. Students with an approved exemption from clerkship assignments outside of the local area will be distributed evenly among the clerkship sequences.Students with exemptions will be given priorityfor a location within 1 driving distance from Burlington; however, students with exemptions will lose flexibility when it comes to choosing their clerkship sequences.
To be considered for a site exemption and given approval to complete all clerkship rotations at UVM Medical Center, this form must be submitted through Oasisno later than noon, two weeks prior to the October clerkship lottery.The Associate Dean for Students will review and process the request prior to the lottery. Requests received after the annual deadline will not be considered except in the case of emergent personal, medical or family issues, and are subject to capacity. If space is not available, the student is encouraged to meet with the Director of Student Support or the Associate Dean for Students to discuss alternative options.
In cases where an unexpected issue arises during the clerkship level, students have the option to request a temporary re-assignment to UVM Medical Center for an upcoming clerkship. Temporary re-assignment is based on clerkship availability.To request a temporary exemption students will also need to complete and submit this form through Oasis.
Ifany of these exemptions apply to you, select the checkbox next to the relevant exemption(s) thenupload this form and any relevant non-medical supporting documentation to your “Exemptions” academic history tab in Oasis, under the “Exemption Request (Student Upload)” section. Oasis will notify you when the Associate Dean has uploaded a decision.
IMPORTANT:Documentation to support a medical request should not include any medical information. When working with SAS, medical information should be submitted directly to SAS, and only the SAS accommodation letter should be uploaded to Oasis with this form.
Request:
Name: Click here to enter text.Date Submitted/Uploaded to Oasis: Click here to enter a date.
Type of exemption requested:
☐ Clerkship Year—all rotations within 1 hour driving distance from Burlington.
☐ Temporary—specific rotation within 1 hour driving distance from Burlington, specify rotation: Click here to enter text.
Check Applicable Grounds:
☐ I have children under age 18 living in my household.
☐ I have a significant medical condition/disability that requires ongoing treatment locally or limits my ability to travel. (SAS accommodation letter required. Please note that completed documentation may take 10 business days for review.)
☐ I have a family member with a significant medical condition for whom I provide care locally.
Details:Note that local placement is within a 1 hour driving distance of Burlington. If you need to be placed within the Burlington area for any reason provide details regarding this request here.
Click here to enter text.
Decision:
☐ Approved
☐ Denied
Electronic Signature, Associate Dean for Students:Click here to enter text.
Decision Date:Click here to enter a date.
Review Notes (for office use only): Click here to enter text.