International Elective Objectives Form

If you will be taking part in an international elective then this form must be completed before you leave Edmonton for the location at which the elective will take place.

If you didn't fill out an assessment form prior to leaving for your elective, you can still submit an evaluation of the elective. On this form, just enter all the data marked with an asterisk (*).

Applicant Information

*Surname:

*Given Name:

*M.D. Class of: (yyyy; eg. 2004)

Elective Information

*Country:

*City:

*Intended Duration of Elective: weeks (From (mm/dd/yyyy) to (mm/dd/yyyy))

Is the elective run by a governmental/non-governmental organization or international company (for example CIDA or Child Family Health International)? YESNO
If YES then please give the name of the organization

Main Hospital/Health Centre at which you will be working:

How did you find out about the elective (eg. website, relative, friend, elective catalogue)?

How can we contact you?

How will the elective be funded/financed?

What are your learning objectives (must be measurable)?
What do you want to get from this experience?

Has a supervisor been arranged? YES NO
If YES then please provide accurate contact information for the supervisor

Address:

Phone:

Fax:

Email:

If this information changes then please revise it upon your return, in the elective assessment form

Who are your local advisors (i.e. U of A)?

Will there be a coursework/lecture component to the elective? YESNO

Language Requirement(s) of Elective:

Language(s) Spoken:

Will you be traveling alone? YESNO

Additional Comments:

Today's Date:

Password (required for you to fill out assessment form upon return):

Re-Type Password:

Your email address:

*Country:
*City:

*Intended Duration of Elective:	weeks (From (mm/dd/yyyy) to (mm/dd/yyyy))

Is the elective run by a governmental/non-governmental organization or international company (for example CIDA or Child Family Health International)?	YESNO If YES then please give the name of the organization

Main Hospital/Health Centre at which you will be working:

How did you find out about the elective (eg. website, relative, friend, elective catalogue)?
How can we contact you?
How will the elective be funded/financed?
What are your learning objectives (must be measurable)? What do you want to get from this experience?

Has a supervisor been arranged?	YES NO If YES then please provide accurate contact information for the supervisor
	Address:
	Phone:
	Fax:
	Email:
	If this information changes then please revise it upon your return, in the elective assessment form

Who are your local advisors (i.e. U of A)?

Will there be a coursework/lecture component to the elective?	YESNO

Language Requirement(s) of Elective:

Language(s) Spoken:

Will you be traveling alone?	YESNO

Additional Comments:
Today's Date:

Password (required for you to fill out assessment form upon return):

Re-Type Password:
Your email address: