AREA HEALTH EDUCATION CENTERS SYSTEM
Office use:
AHEC_______________
Date________________
UofL Health Sciences Center
FACT SHEET
INSTRUCTIONS:
Please complete the entire form with signature at least four weeks prior to the beginning date of the rotation. A
fact sheet must be completed for every AHEC rotation.
1. Name: Last, First
Email: userID@louisville.edu
Employee ID #:
9. School in which enrolled
Medicine
Dentistry
Nursing
Allied Health
2. S.S. #: ***-**-****
Date of Birth: 1/1/11
3. Sex
Male
4. Marital Status
10. Program Year
Undergraduate
Graduate
Resident
Female
Single
Social Work
Married
11. Graduation Date (or completion of residency)
Month:
Year:
5. Number of Children:
6. Ethnic Background
Amer. Indian
Asian
White
Hispanic
12. Family residence at time of high school graduation.
City:
County:
State:
Zip:
Black
Other
7. Current Phone #: (502) 555-5555
Beeper #: (502) 555-5555
Cell Phone #: (502) 555-5555
13. Approx. population of #12
Under 1,000
1,000 – 24,999
25,000 – 49,999
8. Current Address
Street:
City:
State:
Zip:
14. Description of Rotation
Department:
U of L Med/Peds
Course Name:
AHEC
Dates of Rotation:____
Number of Weeks:
4
Name of Preceptor:
Hospital / Clinic:
City of Rotation:
50,000 - 99,999
100,000 & above
Required
or Elective
________________________
County
Departmental Coordinator Approval
15. Housing Arrangements (check all applicable):
A.
I want AHEC to help arrange housing
B.
I will arrange my own housing
Date and time of arrival at rotation site
Date:
C.
D.
E.
Smoking
Non-Smoking
I will need AHEC rent supplement
I will stay with my family or friends-no rent
I will commute (no travel allowance)
Approximate Hour:
Pet Allergies
AM PM
Note: If you check B and/or D, please provide an address and phone number where you can be reached while on
rotation.
Street Address
Town
Phone #
16. PLEASE SIGN AND DATE FACT SHEET
Signature
Date