Boston University Medical Campus
Graduate Medical Education

Name of Residency Program:

Name of Program Director:

Year in Program:
PGY 1
PGY 2
PGY 3
PGY 4
PGY 5
PGY 6
PGY 7
PGY 8
—

Start Date of Rotation: End Date of Rotation:

Explain the necessity of this away elective:
Enter your explaination here, please.

What are your Goals & Objectives for this Rotation:
Enter the Goals & Objectives for this rotaion here, please.

Name of Elective Rotation Site:
Enter complete name and mailing address here, please.

Name of On-Site Supervisor & Contact information:
Enter name and mailing address here, please.

Name of On-Site Contact (if different from Supervisor):
Enter name and mailing address here, please.