• Clerkship Change Request Form

  • This form is used by medical students to request changes to a required clerkship

    • The form must be completed at least 4 weeks prior to the start date of a clerkship.
    • Completion of this form is a request, but does not guarantee re-assignment.
    • Please email the clerkship director prior to submitting this form to discuss your plans for change! 

     

    Phase 2 students can only request:

    • Site changes

    Legacy students can request:

    • Site changes
    • Date changes
    • Drop a clerkship
    • Add a clerkship

    Note: You can Drop one clerkship and Add a new Clerkship with one form submission. You can also choose to do it separately. 

  • Student Information

  • Class Year*
  • Form Request type
  • Type a question
  • Start of Rotation - DSA
     - -
    2 digit month, 2 digit day, 4 digit year
  • Requested Start of Rotation - DSA
     - -
    2 digit month, 2 digit day, 4 digit year
  • Requested Start of Rotation - Add
     - -
    2 digit month, 2 digit day, 4 digit year
  • Original Start of Rotation - Drop
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you requesting this change at least 4 weeks prior to the start date of the clerkship?*
  • Have you emailed your clerkship director BEFORE submitting this form?*

  • Please email your clerkship director BEFORE submitting this form to discuss the availability

    • Phase 2 

    • Clerkship Change Request Phase 2

    • Originally scheduled Clerkship and Site - Phase 2*
    • Type a question
    • Requested New Site - Phase 2*
    • Start Date of Clerkship*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Assigned Rotation*

    • Requested site must be different than Original site. 

    • Legacy 

    • Clerkship Change Request (Legacy)

    • Request type*
    • Change Dates and/or Site (select one or both)*
    • Add and/or Drop (select one or both)*
    • Request to change (select all that apply)
    • Originally scheduled Clerkship and Site - Legacy*
    • Requested New Site - Legacy*
    • Original Start Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Original Block*
    • Requested New Start Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Requested New Block*

    • Requested site must be different than original site. 

    • Add a clerkship 

    • Adding a clerkship information

    • Requested Clerkship & Site (Added Clerkship) - Legacy*
    • Requested Start Date (Added Clerkship)*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Requested Clerkship Block (Added Clerkship)*
    • Drop a clerkship 

    • Dropping a clerkship information

    • Requested Clerkship & Site to DROP - Legacy*
    • Original Start Date of Clerkship to DROP*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Block of Clerkship to DROP*
    •  
    • Student Attestations and Agreements 

    • Student Attestation

    • By clicking the checkmark below, you attest that you acknowledge the policy and deadlines outlined below:

      • Changes are allowed, on a first-come first-serve basis, up to 4 weeks before the start of a clerkship if there is room in the clerkship
      • Availability is determined by the clerkship director. If not, only 1-to-1 switches can take place up to 4 weeks before the first day of a clerkship. 
      • This request form will be routed to the Clerkship Director and Registrar's Office for approval

      Compliance Requirements for Affiliate Sites:

      If you are switching to a clerkship that is scheduled at the Bronx VA, Valley Hospital, or Elmhurst you are responsible for ensuring you have met the compliance requirements of that site. Without Clearance, you risk being sent back to MSH on your first day at a site. If you have any questions contact the Compliance.MD.Program@mssm.edu

    • OGstartdate
       - -
      2 digit month, 2 digit day, 4 digit year
    • reqstartdate
       - -
      2 digit month, 2 digit day, 4 digit year
    • Should be Empty: