M3 Clerkship Placement Survey for Academic Year 2014-2015

Course Structure

Family Medicine Clerkship rotation consists of two required core educational blocks (4 weeks each). For the most part students will be assigned to one of the UT Family Medicine residency training centers for one block. During the other block students will be assigned a community based Family Medicine clinical faculty (approved preceptor) office. It is possible that you can be assigned to a comprehensive community based site for the entire 8 weeks, including distant sites where housing relocation would be required. The following information, if provided, will be taken into consideration when assignments are being made. However, the final assignments will be made by the department based on location, clinical faculty, and appropriate training environment availability. Please have your form submitted no later than one month prior to start date. Failure to do so will result in placements being made of our choosing, and cannot be changed once final placement is complete. Please get your preferences in early!!! We do ask your cooperation in providing the following basic information including special educational requests.

APPLICATION

Section I

Select Preferred Course Registration:



Note:**Completed forms for Knoxville and Chattanooga will be forwarded to their respective clerkships.


First Name: Middle : Last Name:

Telephone (w/ area code): Cell Phone/Pager (w/ area code):

Emergency Contact and Phone (with area code):

UTHSC E-mail: Alternate E-mail (if available):

Current (local) Address:

City: State or Country: Zip:

Hometown (town/city and state/country):

Marital Status:

Do you speak any foreign languages? If so, mention them here:

Personal Handicaps/Living Restrictions:

Please explain any personal handicaps or living restrictions, if you answered 'yes' to the previous question:

500 characters left

Section II

Review and complete the following if you have elected Course FME1-3001/F: Memphis

Examples of communities where approved training sites exist that are assigned through UT Memphis - FME1-3001/F (subject to scheduling availability): Including F.M. Residency Training Centers/Hospitals in Jackson (housing/transportation stipend available for Jackson only) (Jackson/Madison); Memphis (St. Francis):

Tennessee

  • Bartlett*
  • Bristol
  • Collierville*
  • Columbia
  • Cookeville
  • Cordova*
  • Covington*
  • Dickson
  • Fayetteville
  • Franklin
  • Gallatin
  • Germantown*
  • Greenville
  • Huntingdon
  • Jackson
  • Jamestown
  • Jefferson City
  • Jellico
  • Johnson City
  • Lawrenceburg
  • Lexington
  • Livingston
  • McKenzie
  • Memphis*
  • Munford*
  • Murfreesboro
  • Nashville
  • Newport
  • Selmer
  • Sewanee
  • Shelbyville
  • Sparta
  • Tullahoma
  • Union City
  • Waynesboro
  • Winchester

Arkansas

  • Pine Bluff**
  • Forrest City*
  • Jonesboro**
  • Little Rock**
  • Fayetteville**

Mississippi

  • Senatobia*
  • Southaven*
  • New Albany
  • Olive Branch*

*Considered as Memphis area ** Training sites that provide free housing, provided you need to relocate

Clerkship Location Preferences

Please rank in order of preference where you would like to serve the clinical phase of the clerkship, including residency training centers and community faculty offices. Feel free to suggest the name(s) of potential faculty physician-preceptor.

Contracts with clinical faculty for the purpose of student placement must be handled by the Department of Family Medicine. Independent agreements initiated by students with preceptors will not be honored.

First Choice Preferred Town/City:

Preferred Faculty/Preceptor (if known) :

Second Choice Preferred Town/City:

Suggested Faculty/Preceptor (if known) :

Third Choice Preferred Town/City:

Suggested Faculty/Preceptor (if known) :

Section III

Additional Comments

What other information would you like us to consider in finalizing your assignment? Please enter that information below:

1500 characters left

It will be the students' responsibility to keep the Department of Family Medicine informed of any changes in address, telephone number, and/or training site preferences.

To complete the submission of your preceptorship application form, in the space provided below, please type in the 2 words pictured, then click the "Submit" button. Thank you for your submission.