Forms (in alphabetical order)
An Absence Request is required for all absences from UMDNJ-SOM clinical rotations, including conference attendance, taking COMLEX, going for interviews and utilizing your personal day. You must obtain the Clerkship Director's signature a minimum of 14-30days in advance of the requested absence date. Absences during electives must be arranged directly with the elective site, and do not require an Absence Request.
Change in Rotation 2012-2013
The Change in Rotation form is required for all changes to the Year III or Year IV schedule, including change of dates, sites, or clerkship. This form should be turned in to the Clinical Education Coordinator at least 30 days prior to the clerkship start date. Schedule changes will not be made until this form has been received.
Clinical Evaluation (including CME Attestation)
The Clinical Evaluation Form is the form used to grade students on their clinical rotations. Students are given copies of this form each year. If you do not have a copy of your form handy, you may print a copy from here. Each clerkship has specific rules regarding completion of the evaluation form(s), so check with your Clerkship Director if you have any questions.
Also attached to the Clinical Evaluation is the Continuing Medical Education (CME) Attestation form which Preceptors may complete to receive CME credits for participating in educating you. The CME Attestion can be sent to CME Coordinator noted on the bottom of the form.
Students at the University of Medicine and Dentistry of New Jersey may request permission to participate in a program of study or other educationally related experiences (“Program”) outside the University or its affiliates. In consideration for being permitted to participate in a non-affiliated Program, students will have to accept certain responsibilities and risks noted on the linked waiver. This Statement does not eliminate the need for students to sign additional waiver forms with Academic Affairs.
The 3rd Year Radiology Application is required for all third year radiology rotations out-of-system. A minimum of 30 days in advance of the start date. You should complete all of Part I, including complete contact information for the site. Then turn in the application, along with any other documents the site may require, to the Clinical Education Coordinator.
4th Year Clerkship Application
The4th Year Clerkship Application is required for all Elective rotations , whether in- or out-of-system and Surgical Specialties, out-of-system. A minimum of 30 days in advance of the start date. You should complete all of Part I, including complete contact information for the site. Then turn in the application, along with any other documents the site may require, to the Clinical Education Coordinator.
Non-Credit Experience Application
An Non-Credit Experience Application may be completed during vacation time or night/weekend hours while on a regularly scheduled rotation.
This form should also be used by first and second year students for medicine-related activities outside of class or summer programs. Several signatures are required.
A request to make up clinical weeks is required for medical, academic, or personal absences from UMDNJ-SOM clinical rotations over 5 days. This is reviewed by the Clinical Education Coordinator and discussed with the Assistant Dean of Student Affairs before time off is approved. All missed weeks are required to be made up before you will be eligible to graduate.
Student electing to rotate internationally must complete the Waiver and Release Agreement. Student completing this form agree that they have secured health insurance with medical evacuation and repatriation coverage, understand the risks in traveling, will follow the laws of the foreign country, along with other terms necessary in rotating internationally. This form would accommany any additional forms noted above to process the request.
Still have questions? Contact:
Fatmata Kabia, M.P.A.
Clinical Education Coordinator
Office of Academic Affairs
One Medical Center Drive, Suite 210
Stratford, NJ 08084-1501