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Application Form

This document is a form for a Dean or senior faculty member to complete to assess a medical student applying for an elective. It requests information about the student's year of study, dates of attendance for their final year, character, academic and clinical abilities, clinical experience, English language proficiency, and any other relevant details. The Dean is asked to sign off on supporting the student's application, either without or with reservation.

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Will Pridmore
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
103 views

Application Form

This document is a form for a Dean or senior faculty member to complete to assess a medical student applying for an elective. It requests information about the student's year of study, dates of attendance for their final year, character, academic and clinical abilities, clinical experience, English language proficiency, and any other relevant details. The Dean is asked to sign off on supporting the student's application, either without or with reservation.

Uploaded by

Will Pridmore
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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THE DEAN OF THE FACULTY OF MEDICINE OR AN APPROPRIATE SENIOR FACULTY OFFICER

IS REQUIRED TO COMPLETE THIS SECTION OF THE APPLICATION FORM

Name of student: ……………………………………………………………………………………………………………….

1. The above named student is presently in year ………. of a ………. year programme.

2. The dates of attendance for the final medical year are ............................... (DD/MM/YY) to ...............................
(DD/MM/YY).

3. General assessment of the student's character and conduct:

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

4. Assessment of academic ability (please circle): BELOW AVERAGE / AVERAGE / ABOVE AVERAGE

5. Assessment of clinical ability (please circle: BELOW AVERAGE / AVERAGE / ABOVE AVERAGE

6. Details of clinical experience to date:

…………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………..

7. Student’s knowledge of English (where English is not first language):

Spoken: ……………………………………………………. Written: ……………………………………………………

8. Any further information which you think might be of assistance:

…………………………………………………………………………………………………………………………………..

9. I support without reservation/with reservation (delete as appropriate) the application from this student for the
proposed elective.

Signature: ……………………………………. Date: ……………………. Official Stamp of


Medical School
Position: …………………………………………………………………………

Medical School: …………………………………………………………………

E-mail address: ………………………………………………………………….

If you have any queries, please email [email protected]

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