Clinical Rotation Application

INTRODUCTION

Utah AHEC offers clinical placement/rotations in medically underserved areas in both rural and urban settings. Depending on the location, students may receive assistance with housing, mileage, and support relative to their placement. The logistics for these placements are arranged for by the Utah AHEC system.

Sponsorships for students in primary care disciplines are provided by various funding agencies. Qualifying students include medical students and residents in family medicine, pediatrics, internal medicine, OB/GYN; physician assistants, advanced practice nurses, pharmacy and dental residents. Placements will typically occur in rural sites and or Community Health Centers. Please be aware that if you qualify and choose to complete an AHEC placement/rotation, you will be regularly contacted by the Utah AHEC Program to track your career choices, as required by the program's federal funding agency, HRSA.

Upon approval, health professions' students are eligible for AHEC assistance in identifying clinical training opportunities in medically underserved sites. Applicants should be in good academic standing and have completed at least the first year of their educational program.

INSTRUCTIONS

Please complete this application in detail and include a written statement describing your interest in participating in an AHEC training opportunity. Applications must be submitted 6 weeks prior to start date. Please send questions or comments to Carrie Torgerson (torgersen@suu.edu)

Applicant Information

Title:

First Name:

Middle Name:

Last Name:

Maiden Name/Former Last Name(s):

Date of Birth:

yyyy-mm-dd or mm/dd/yyyy

University:

Unlisted University:

Enter University/College here in school name, town, state format

University Instructor:

The name of your university/college instructor or advisor

Program Grade Level:

Discipline:

Discipline choices will be shown once a grade level has been selected

Current Year of Training:

Post Graduate Resident:

Are you a Post-Graduate Resident?

Projected Graduation Date:

yyyy-mm-dd or mm/dd/yyyy

Current Address

Current Address:

Current Community:

Current Zip Code:

Current Unlisted Community:

Unlisted current community in city,state format

Current Phone Number:

Current Cell Number:

Current Pager Number:

Email Address:

Permanent/Parent's Address

Permanent Address:

Permanent Community:

Permanent Zip Code:

Permanent Unlisted Community:

Unlisted permanent community in city,state format

Permanent Phone Number:

Permanent Cell Number:

Permanent Pager Number:

Demographic Information

Gender:

Hispanic or Latino:

Are you Hispanic/Latino?

Race:

Spanish Speaking:

Are you a Spanish speaker?

Raised in Rural Area:

Were you raised in a rural area?

Other Languages Spoken:

What other languages (beside Spanish and English) do you speak?

Economically disadvantaged background:

Are you from an economically disadvantaged background?

Disadvantaged can be defined as, but not limited to the following: (one definition qualifies as disadvantaged)
Prior to high school graduation:
- You lived where there were few medical providers at a convenient distance,
- Your family had limited income and/or you were required to contribute to the family income,
- You or your family had used federal or state assistance programs such as school lunch, WIC, subsidized housing, food stamps, etc.

Utah High School:

If you graduated from a Utah High School, please identify it here

Previous AHEC Participation:

Have you previously participated in AHEC activities?

National Health Service Corp. Scholar:

Are you a National Health Service Corp. Scholar?

Site Information

Required Hours:

Number of hours required for this training experience

Preferred Start Date:

yyyy-mm-dd or mm/dd/yyyy

Preferred End Date:

yyyy-mm-dd or mm/dd/yyyy

Preceptor Identified:

Have you identified the preceptor?

Preceptor Contacted:

Have you contacted the preceptor?

Preferred Preceptor and/or Location (If Identified)

Preceptor First Name:

Preceptor Last Name:

Preceptor Address:

Preceptor Community:

Permanent Zip Code:

Preceptor Unlisted Community:

Unlisted preceptor community in city,state format

Preceptor Phone Number:

Preceptor Email Address:

Preceptor Facility:

Enter the facility at which the preceptor works (if you know it)

Housing Requirements

Every attempt is made to identify safe and clean accommodations, which range from motel rooms (with fridge and microwave) to apartments to private rooms in local residents' homes. Because funding for housing is limited, we also appreciate students/residents who arrange to stay with friends or relatives living near your rural clinical placement. While we are supportive of including families in this rural experience, family housing that is wholly sponsored by Utah AHEC is only available in St. George (for approved rotations in outlying communities like Hurricane, Santa Clara, Enterprise), Beaver and Cedar City. Depending on availability, family lodging may also be available in other communities for students who are willing to pay additional charges.

Cancellation Policy: Students may be billed for any lodging deposits paid in advance by AHEC if the placement location is changed or cancelled.

Housing for Self:

Check if you will need assistance arranging lodging for yourself

Housing for Spouse:

If requesting assistance arranging housing, will your request include your spouse

Housing for Children:

If requesting assistance arranging housing, will your request include your children

Number of Children:

Number of children included in lodging assistance request (if you made such a request)

Age Range of Children:

Age range of children included in housing assistance request (if you made such a request)

Other Funding Support:

Is this rotation is supported by funds other than AHEC

Other Funding Notes:

Please provide details if this rotation is supported by funds other than AHEC

Additional Information

Additional Information:

Use this area to address all of the following points:

- Describe your interest in clinical training in rural and other medically underserved communities.
- Describe reasons you are interested in this training opportunity.
- Summarize your personal background information that will assist you in making this a positive clinical training experience.
- If you are an out of state student, please discuss why you wish to come to Utah for this training experience

Special Needs:

Please describe any special needs you may have

Resume (Optional):

Certifications

Career Updates: I understand that I will be contacted with a request to update my career information and will respond to those requests in a timely manner

Utah AHEC Database

Clinical Rotation Application

INTRODUCTION

INSTRUCTIONS

Applicant Information

Current Address

Permanent/Parent's Address

Demographic Information

Site Information

Preferred Preceptor and/or Location (If Identified)

Housing Requirements

Additional Information

Certifications