Graduate Medical Education: Application for Off-Site "Away" Elective Rotation

Residents desiring to complete an away rotation must complete this form as early as possible. The Office of Graduate Medical Education will notify the resident regarding the outcome of the request.

Are you currently working for Penn State Health Milton S. Hershey Medical Center on a VISA?

YesNo

Please note that if you are currently working on a VISA, you are not permitted per VISA regulations to work at locations other than Penn State Health Milton S. Hershey Medical Center. You are not eligible to apply for an Away Elective Rotation. Please close out of this form.

Please continue with the application process and requirements.

Resident First Name

Resident Last Name

Resident Email

Residency Program

Program Director Name

Program Director Email

Anticipated Date to Start Rotation

Anticipated Date to End Rotation

Location of Rotation (Institution Name and Address)

Description of Facility

Preceptor Name

Preceptor Email

Educational Goals and Objectives for this Elective Rotation

Brief Personal Statement: How will this rotation fulfill your educational/career goals?

Please attach a letter of agreement from the preceptor stipulating: a) agreement for the rotation during the requested time period; b) acceptance of the stated goals and objectives for the rotation; and, c) agreement to complete and send an evaluation on your performance to your Program Director at the completion of the rotation.

Your submission of this form constitutes your agreement to the information stated here. Upon submission, your program director will be emailed a notification to complete their verification of this information. Requests cannot be processed without program director validation; please work with your director to ensure they complete the next step.

Contact Information