OMS IV Away Rotation Request Form

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

Name*
First Last
Email*
Please always use your Burrell College of Osteopathic Medicine Email (ex firstname.lastname@burrell.edu )
Enter Email Confirm Email
Does Program Use:*
- VSLO/VSAS
- ClinicianNexus
- Audition/GME
- Recruited an away elective preceptor
Is the Rotation Start Date at least 90+ days away?*
- Yes
- No
Please contact clinicaleducation@burrell.edu
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
Proof of Affiliation Agreement Status:*
Note: It is the student’s responsibility to ask the preceptor/facility if an Affiliation Agreement is required on their end. Please upload a screen capture of your communication with the facility stating if an Agreement is required or not.
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.
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:*
Preceptor CV:*
Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx, Max. file size: 20 MB.
Preceptor Malpractice:*
Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx, Max. file size: 20 MB.
Proof of Audition/GME 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.
Please upload a screen capture of proof that this rotation is an audition or is held at a GME facility. In order to receive credit for the rotation, you will need to submit your preceptor’s CV and malpractice insurance once they are assigned.
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.
Examples include a screen capture of communication from facility or preceptor accepting you for the rotation dates requested.
Student Signature:*
Date*
MM slash DD slash YYYY
Submission of this request form does not constitute approval.
CAPTCHA

Watch Test

OMS IV Away Rotation Request Form

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

Rotation Site / Institution

Office Manager / Site Coordinator