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

yyyy-mm-dd or mm/dd/yyyy

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

The name of your university/college instructor or advisor

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

Are you a Post-Graduate Resident?

yyyy-mm-dd or mm/dd/yyyy

Current Address

Unlisted current community in city,state format

Permanent/Parent's Address

Unlisted permanent community in city,state format

Demographic Information

Are you Hispanic/Latino?

Are you a Spanish speaker?

Were you raised in a rural area?

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

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.

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

Have you previously participated in AHEC activities?

Are you a National Health Service Corp. Scholar?

Site Information

Number of hours required for this training experience

yyyy-mm-dd or mm/dd/yyyy

yyyy-mm-dd or mm/dd/yyyy

Have you identified the preceptor?

Have you contacted the preceptor?

Preferred Preceptor and/or Location (If Identified)

Unlisted preceptor community in city,state format

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.

Check if you will need assistance arranging lodging for yourself

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

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

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

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

Is this rotation is supported by funds other than AHEC

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

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

Please describe any special needs you may have

Certifications