Extramural Request | UAMS Graduate Medical Education

Please select the type of extramural rotation you are requesting and complete the required information. This form will be submitted to the Housestaff Affairs Office and the GME Office for review and approval. For questions please contact askgme@uams.edu.

"*" indicates required fields

Name of Person Filling out Request *

First Last

Email of Person Filling out Request *

Name of Program Requesting Rotation

Resident Requesting Extramural Rotation's Name *

First Last

Resident Requesting Extramural Rotation's PGY Level *

Resident Requesting Extramural Rotation's Phone Number *

Resident Requesting Extramural Rotation's Email

Please select the type of extramural rotation you are requesting *

ACGME Required Extramural Rotation

Elective Extramural Rotation

Please copy and paste the requirement from your ACGME Program Specific Requirements *

Do you have a source of payment for trainee salary/benefits while on the requested rotation? *

Yes

Please attach proof of support of funding for the rotation.

Max. file size: 15 MB.

Please obtain proof of support of funding for the rotation before requesting the elective extramural rotation before proceeding.

Rotation Name *

Dates of Rotation *

Board Eligibility *

I have looked at the board eligibility requirements and this rotation meets those requirements.

This rotation meets board eligibility requirements

Name of Participating Institution for the Extramural Rotation *

Address *

of the Participating Institution for the Extramural Rotation

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Faculty/Physician Rotation Supervisor's Name *

First Last

Faculty/Physician Rotation Supervisor's Email *

Faculty/Physician Rotation Supervisor's Phone *

Please attach the goals and objectives for the rotation *

Max. file size: 15 MB.

How will this rotation enhance the educational experience of trainees? *

What training deficiency at UAMS caused the program to need this rotation? *

How is this deficiency being addressed for future educational training? *

Program Director's Name *

Program Director's Acknowledgement *

I endorse the educational value that this rotation offers in the education of the trainee and have approved the rotation for the trainee listed above. I am aware that adequate supervision of the trainee must be provided at the participating institution. I acknowledge that communication has been made with the faculty supervisor at the rotating site regarding the educational goals and objectives, supervision and evaluation of the trainee during the rotation.

I am in agreement with the terms of the extramural rotation.