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UNIVERSITY OF PENNSYLVANIA
PERELMAN SCHOOL OF MEDICINE
Registrar’s Office
Suite 100, Stemmler Hall, 3450 Hamilton Walk
Philadelphia, PA 19104-6087
Phone: 215-898-4646/ Fax: 215-573-5578
Student’s Name ___________________________________ Year in School_________
Title (as you want it to appear on your transcript):
_____________________________________________________________________
Exact Begin and End Date (month/day/year): _______________________________
Hours per Week _______________________
Days per Week _________________
Mentor’s Name and Title: ________________________________________________
Complete Address if not a Penn/CHOP Faculty:
Are you receiving funding: Yes/No
Funding*: _____________________________________________________
(See attached list of names; let us know if your funding source is not listed.)
Please answer the questions below:
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Is this a clinical rotation:
Is this a public health research rotation:
Is this a clinical research project:
Is this a basic science project:
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Is international/part international:
yes/no
If yes complete global health form found on:
http://www.med.upenn.edu/globalhealth/penn_students.shtml#gheregistration
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Revised 4/17/14
yes/no
yes/no
yes/no
yes/ no
BRIEF DESCRIPTION OF ACTIVITY
(If patient contact is involved, please indicate who the supervisor will be.)
Mentor Approval: I have read the student’s plans and agree with the information provided. I will
provide an assessment of his/her performance at the end of this educational experience.
___________________________________
Mentor Signature/Date
______________________________________
Associate Dean for Curriculum Signature/Date
Please return the form to Maria Hernandez, Academic Programs, Suite 100 Stemmler Hall.
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Revised 4/17/14
Do not print these pages –Just submit page one and two to Maria
*Funding Sources
 Abbott Medical Student Clinical Preceptorship/ACR REF
 Agnew Society Summer Scholarship
 Alpha Omega Alpha Student Research Fellowship
 American Austrian Foundation Max Kade Fellowship
 American College of Rheumatology Preceptorship
 American Dermatological Association Medical Student Fellowship
 American Heart Association
 American Society of Hematology Minority Medical Student Awards
 Arnold P. Gold Student Summer Research Fellowship
 BOTUSA Project Medical Student Fellowship
 Center for AIDS Research
 Center for Clinical Epidemiology and Biostatistics Summer Fellowship
 Center of Excellence
 Centers for Disease Control Hubert
 Fellowship
 Centers for Disease Control Fellowship in Applied Epidemiology
 Cleft Palate Foundation Children's
 Craniofacial Association Research Grant
 Department Funding
 Departmental/mentor funding
 Doris Duke Clinical Research Fellowships
 Focus on Health and Leadership for Women's Medical Student Fellowship for Penn Med
Students
 Fogarty Ellison
 Overseas Fellowship in Global Health/Clinical Research
 Ford Foundation
 Frontline Medicine
 Fulbright Scholar Program
 GCRC Mentored Medical Student Clinical Research Program
 Global Health Programs
 Gold Foundation Summer Fellowship
 HHMI Research Training Fellowships for Medical Students Program
 Interventional Radiology Summer Fellowship
 Mabel E. Leslie Endowment
 Marjorie B. Cohen Foundation
 Measey Foundation Fellowship
 Medical Student Summer Orthopaedic Research Fellowship (Ortho Research and Educ
Foundation)
 Medical Students for Choice
 Mentor Funding
 Minority International Research Training Program
Revised 4/17/14
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NHLBI Short Term Research Training
NIDDK Medical Student Research Training
NIDDK Short Term Research Training
NIH Cancer and Radiation Biology Research Training Grant
NIH Clinical Research Training Program for Medical and Dental Students
NIH Other Funding
NIH Pre-Doctoral
Intramural Research Training Award for Graduate or Medical Students
NIH Research Supplements for Underrepresented Minorities
NIH Summer Research Fellowship Program
Neurobiology of Otorhinolaryngology: National Institute on Deafness and Other
Communication Disorders
Paulette and Denzel Washington Gifted Scholars in Neuroscience Graduate Fellowship
Penn URF Grant
Petrus Camper Fellowship
Pfizer Health Literacy Initiative
Princeton in Africa
Radiological Society of North America Research and Education Fund
Stanley J. Sarnoff Fellowship in Cardiovascular Research
Stolley Travel Award
Student Fellowship in Anatomic Pathology
Revised 4/17/14