Individually Designed Elective
Due 60 days prior to start of the elective
Student Name
Banner ID
Student Phone
Year
Student Pager
Student Address
Student Email
@students.ecu.edu
Elective Title
Email:
Elective Director/
Preceptor
for evaluation
Name of Practice or
Hospital
Address/Location of
Elective
Street Address/PO Box
City/State/Zip
Fax
Telephone
Meeting Time (where
and when to report on
1st day of rotation)
Date
State Date:
Finish Date:
Duration (check one)
______________ 2 weeks
______________ 4 weeks
Overall Course Goal
Educational Objectives
(min of 3)
1.
2.
3.
Readings/ Course
Literature
The following materials will be used- assignments will be as individualized.
Activities/Students
Experience
Describe the course activities:

Lectures, clinics, conferences to be attended?
Official format approved by ECC 10/12/06
Individually Designed Elective
Due 60 days prior to start of the elective

In what location will students be observed on this elective?

How will students receive mid-course, formative feedback of their performance?

Oral presentation, written assignments required?

Research requirement?
Describe on call requirements, if applicable (including specific duty hours):
Other Requirements
Please provide any other pertinent information below:
Evaluation
Describe how student performance will be assessed and how the course grade will be determined:
I certify that this elective will be directed by the identified Course Director or Preceptor, who is member of the
faculty of the Brody School of Medicine or a physician who has been approved to direct this elective. I also
certify that the department will provide the needed resources to conduct this elective during the rotation blocks
shown.
BSOM or SITE Course Director/Preceptor’s
Signature:________________________________________________________________Date_____________
Student’s Signature: ________________________________________________________Date____________
Please Return To:
The Brody School of Medicine at East Carolina University
Office of Student Affairs, Brody 2S-20
Greenville, NC 27834
Telephone: (252) 744-2278
Fax: (252) 744-3250
Office Use Only:
This Elective will meet the following requirement: (Check all that apply)
Primary Care Elective __________
Acting Internship Elective __________ Miscellaneous Elective_________
M4 Curriculum Chair/Subcommittee Approval: _______________________________________________________Date______________
(Signature)
Official format approved by ECC 10/12/06