OMS IV Away Rotation Request Form

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Name*
First Last
Email*
Please always use your Burrell College of Osteopathic Medicine Email (ex firstname.lastname@mybcom.org )
Enter Email Confirm Email
Hidden
Date Submitted:
MM slash DD slash YYYY
Rotation Specialty:*
Requested Dates for Rotation:
Rotation Start Date:*
MM slash DD slash YYYY
Rotation End Date:*
MM slash DD slash YYYY
Rotation Site / Institution
Name:
Address:
Street Address City State / Province / Region ZIP / Postal Code
Phone:
Fax:
Preceptor Name:
First Last
Preceptor Email:
Hidden
Preceptor Medical License Number:
Do Clinics or Hospitals the Preceptor practices/rounds at need an Affiliation Agreement?*
- Yes
- No
Note: You should ask the Doctor prior to submitting this form
Hospital/Clinic Name:
Hospital/Clinic Contact Name:
First Last
Hospital/Clinic Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hospital/Clinic Email:
Hospital/Clinic Phone:
Office Manager / Site Coordinator
Manager / Coordinator Name:
First Last
Email:
Address:
Street Address City State / Province / Region ZIP / Postal Code
Phone:
Fax:
Does Program Use:*
- VSLO/VSAS
- ClinicianNexus
- Own Application
Note: Student will be given some responsibility to assist in paperwork necessary for credentialing of their preceptors and establishing affiliation agreements. Preceptors must be credentialed and both the Institution and Burrell College of Osteopathic Medicine must execute agreements no less than ninety (90) days prior to the anticipated rotation start date, or the rotation may be cancelled.
Proof of Confirmation:*
Drop files here or

Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx, Max. file size: 20 MB.
Student Signature:*
Date*
MM slash DD slash YYYY
Submission of this request form does not constitute approval.

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OMS IV Away Rotation Request Form

Please use the Microsoft Edge browser when filling out this form.

Rotation Site / Institution

Office Manager / Site Coordinator