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  5. Extramural Request

Extramural Request

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 * Required
Resident Requesting Extramural Rotation's Name * Required
Please select the type of extramural rotation you are requesting * Required
Do you have a source of payment for trainee salary/benefits while on the requested rotation? * Required
Max. file size: 15 MB.

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

Board Eligibility * Required
I have looked at the board eligibility requirements and this rotation meets those requirements.
Address * Required
of the Participating Institution for the Extramural Rotation
Faculty/Physician Rotation Supervisor's Name * Required
Max. file size: 15 MB.
Program Director's Acknowledgement * Required
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.
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Mailing Address: 4301 West Markham Street, Little Rock, AR 72205
Phone: (501) 686-7000
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