1. Name of Elective: 

2. Department:

3. Faculty Responsible for Elective:

4. Telephone Number: 

5. E-mail Address: 

6. DESCRIPTION OF COURSE ACTIVITIES AND LOGISTICS:  Please provide a concise but complete description of the course activities and experiences students will engage in during this elective course.  Include performance expectations and any necessary logistical details.

   STUDENT LEVEL:  Is this course appropriate for Year Three students if prerequisites listed below are met?

   	Yes, include this course in the Year Three Elective Catalog (maximum course length for Year Three students is 2 weeks).
   	No, this course is appropriate ONLY for students who have successfully completed ALL Year Three Clerkships.

7. OBJECTIVES:  Please list the specific and attainable learning objectives designed for this elective.

8. EVALUATION:  Please describe the method(s) by which you will determine that the student has achieved the course objectives (observation, oral exam, written exam, logbook entries, case presentation, oral presentation, written essay, discussion with faculty, etc.).  NOTE:  If there is a clinical component in this elective, students are required to maintain a logbook of patient encounters.:

9. ADDITIONAL FACULTY INVOLVED:

10. PREREQUISITES:  (mark all of the following that apply)

	Student to contact course faculty weeks before beginning elective
	Successful completion of all third-year clerkships.
	Successful completion of the following clerkship(s):
	Other (Please specify):

11. ENROLLMENT:  Indicate the minimum and maximum number of students you will take at one time in this elective.   

MINIMUM:       MAXIMUM: 

Please indicate any additional enrollment restrictions that apply:

12. SCHEDULE:  Please specify the LENGTH of the elective, and whether it is FULL-TIME or HALF-TIME.  Half-time electives are offered mornings only or afternoons only.  EXTENDED ELECTIVES are offered on Thursday afternoons only, in 5-week blocks (maximum of 6 blocks or 30 weeks).  All students taking electives in Springfield are released from regular elective activities on THURSDAY AFTERNOONS.  Mark all of the following that apply:

A.     SCHEDULE:  (select one)

Full-time
Half-time
	mornings
	afternoons
Extended

B.     LENGTH

Regular	Extended
1 week   2 weeks   4 weeks	5 weeks   10 weeks

 

Credit Hours:      Minimum:    Maximum: