ICM-1 Clinical Placement, Spring 2010

PLEASE NOTE: CCHERS students will continue at their sites, and do not need to fill out this form.

As part of the second semester of ICM-1 you will be shadowing a clinician in an ambulatory setting for 10 afternoons. Please indicate your preference for type of clinical placement on this form. We will attempt to give you your first or second choice, but cannot promise this.

Student Name:

Student Address:

Preferred Email Address:

Phone Number:

Will you have access to a car this spring?

Yes

No

All students travel as part of the ICM courses whether or not they have access to a car. Many sites that are accessible by public transportation take longer to get to than sites requiring cars. Any student who travels off campus for an ICM placement will receive a small travel stipend to help with the potential added expense.
Are you fluent in any languages other than English? Which ones?
Please list:
Have you placed out of any courses? Which ones?

Some mentors are available only at days and times other than Thursday afternoons. If you have placed out of a course and plan to do something else during that time (some students help out in the courses they’ve placed out of, for example), please indicate this above.
Are you available evenings? Which ones?

Please rank your choices for a clinical placement:

(1=first, 2=second etc.)

Family Medicine

Internal Medicine

Pediatrics

Emergency Medicine (student must have a flexible schedule)
This course works best with a primary care placement, but please note below if you have a particular interest in a specialty.

Other

If you have any questions or problems, please contact Ginny Potter (617-414-7449, gpotter@bu.edu).

Primary teaching affiliate
of BU School of Medicine