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New Senior Elective Clerkship Proposal Form
Instructions
To ensure that the SOM meets the Liaison Committee on Medical Education (LCME) standards for accreditation,
please complete all items on this form. This form should accompany: 1) a copy of the course syllabus that is
provided to students, and 2) the UCSD Request for Course Approval form.
*Please respond directly on this form and use additional pages as needed.*
1. Course Information
Department:
Course Number (to be assigned):
Course Title:
Course Director(s):
Maximum # of students/session:
2. Teaching methods to promote lifelong learning
 Identify and describe the teaching methods that will be used in the clerkship. (check all that apply)
___one-on-one observation
___demonstrations
___seeking information from medical
literature and other sources
___computer-based instruction
___patient simulations (computer or
standardized patients)
___case-based seminars
___role plays
___*other (please describe)
*Other:

How will methods of instruction and evaluation used in clerkship provide students with the necessary
skills to support lifelong learning? (For example: Self-assessment of learning needs; Independent
identification, analysis and synthesis of relevant information; Assessment of the credibility of
information; Self-reflection exercises)
3. Key faculty/instructors
All course instructors must be familiar with the educational objectives of the course and be prepared for their
roles in teaching and evaluation. They should receive a written copy of the clerkship’s objectives and syllabus and
receive clear guidance from the course director about their roles in teaching.

Will non-faculty members be involved in the instruction of medical students? yes*___ no___
o *If yes, please check which type of non-faculty instructors will assist with teaching:
Fellows___ Residents/Interns___ Graduate Students___ Community Clinicians___ Other___
o *Please describe the roles of non-faculty instructors.
o *Will guidance about their role in teaching be given by the clerkship director? yes___ no___

Will instruction by faculty and non-faculty instructors be directly observed? yes___ no___

Please list any other methods of monitoring instruction (if applicable).

Is there a department program to teach faculty and non-faculty (fellows/residents/interns) teaching and
evaluation skills? yes___ no___
If yes, please briefly describe.
4. Student supervision and clinical observation
In all clinical courses, students must be observed performing a relevant history and physical examination (H&P).
If not applicable, please indicate.

Describe how this will be accomplished.

Identify who will supervise students in patient care settings.

Identify any non-faculty instructor who will supervise students in patient care settings.

Explain provisions for ensuring that cases seen by students will be reviewed.
o
Will submitted H&Ps be reviewed? yes ___ no ___
5. Mid-clerkship feedback
Each student should be evaluated early enough during the clerkship to allow time for remediation. It is expected
that clerkships provide students with formal feedback during the experience so they can understand and
remediate deficiencies. (An email template for providing mid-clerkship feedback is available at [provide URL of EC
website].)
 Describe how this will be accomplished in your clerkship. The mid-clerkship evaluation procedures
should also be included in the syllabus.
6. Types of patients/clinical conditions/required patient encounters
A system should be established to specify the types of patients or clinical conditions that students must
encounter, and to remedy any identified gaps in education. If a student does not encounter patients with a
particular condition (e.g., because it is seasonal), the student should be able to remedy the gap by a simulated
experience (such as standardized patient experiences, online cases, etc.).
 Describe the type(s) of patients and clinical conditions the student is expected to see, and the patient
volume (per day, per week).
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
Describe how the clerkship leadership will determine and monitor types of patients and clinical
conditions that students must encounter.
Policy on Medical Student Work Hours: [Policy summary: Not more than 30 continuous hrs; on-site duty,
including in-house call, not to exceed 24 consecutive hrs (may remain on duty up to 6 add’l hrs for didactics,
pt. transfer care, outpt clinic and to maintain continuity of med/surg care); 1 day in 7 free from all
educational and clinical responsibility average over 4-wk period; 10-hr rest period between shifts.]
7. Formal assessment of course and faculty
The Office of Educational Development and Evaluation conducts online evaluations of all courses and faculty
(including fellows/residents/interns) using standardized assessment tools. You may view the standard
evaluation tools at http://meded.ucsd.edu/ugme/oede/evaluation_mission and click on the link on the lefthand side for the type of course you offer.
 Describe any other procedures that will be used to assess faculty performance in the course and the
course experience.
For Electives Committee Use
Meets Direct Patient Care requirement?
Yes___ No___
If “Yes”, check one:
Inpatient___ Outpatient___ Primary Care___
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