Elective Request Form – Internal Medicine Program

University of Toronto, Department of Medicine
Elective Request Form – Internal Medicine Program

Complete this form for both University of Toronto and/or Non-University of Toronto Electives. Incomplete or modified forms will not be accepted. Elective requests are evaluated based on their ability to meet individual resident career objectives, as they adhere to the requirements set out by the Internal Medicine Program in conjunction with the RCPSC /CANMEDS framework. Requests for an elective already offered as a core internal medicine rotation will not be approved as such.

IMPORTANT: Residents on University of Toronto electives are required to take call with their base hospital site. Please see Portal – Call Information/Responsibilities for a list of University of Toronto affiliated sites and the associated call responsibilities. If any of these exceptions apply to you, contact the Education Coordinator at your base hospital at least four weeks before the commencement of your elective, so they can take this into account in putting together the schedule.

Resident Information

First Name*

Last Name*

Email Address*

Power ID*

Elective Rotation Name*

Base Hospital (at the time of elective)*

PGY level (at time of elective)*

Block Requested*

Academic Year of the Block Requested*

Does your elective proposal include a call requirement?*

Yes

If yes, please provide call details including the number of calls you will be expected to take – will be subject to approval.

Have you been pre-apporoved for vacation at the time of the elective?*

Yes

If requesting vacation during your elective, please indicate dates (*please note that it is your responsibility to make sure that your vacation request has been submitted to your base hospital coordinator):

ELECTIVE DETAILS*

Type of Elective requested:*

University of Toronto

Non University of Toronto

Affiliated Site (Elective Rotation Site):

Enter other…

Non University of Toronto

Location (Hospital/ City/ Province)

Affiliated University

SUPERVISOR INFORMATION (for U of T Affiliated Sites, omit mailing address)

*The supervisor listed below will be responsible for completing your ITER at the end of this elective.*

Full Name*

Title*

Email Address*

Street

City

Province

Postal Code

Country

Telephone

ADMINISTRATIVE ASSISTANT (if applicable)

Full Name

Email Address

ELECTIVE OBJECTIVES

Describe the structure and schedule of the proposed elective:*

If your elective proposal includes a call requirement, include details including the type (e.g. overnight, home, evening) and number of calls during the four week period

Outline which Medical Expert component(s) are being met by the proposed elective*

Outside of the Medical Expert role, what do you hope to achieve during this elective*

Please identify 2-3 EPAs you will be assessed with on this elective. You will need 8 assessments completed + procedural ones.*

If completing a clinical rotation, describe how this rotation differs from the core rotations offered by the Internal Medicine program*

Describe how this elective will contribute to your career goals*

APPROVAL LETTERS

For out of province electives, the Department of Medicine office will not automatically supply a copy of the elective approval letter to both the licensing agency and post-graduate office of your host institution. If the approval letter must be submitted to any additional parties (including the above), please provide their contact information below:

Email Address

By checking this box you confirm that: (a) you have read through the instructions fully and carefully, (b) you have contacted your elective supervisor and confirmed that they are able to accommodate you, and (c) all information provided is true and accurate.

I understand*

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Elective Request Form – Internal Medicine Program

University of Toronto, Department of Medicine Elective Request Form – Internal Medicine Program

Resident Information

Non University of Toronto

SUPERVISOR INFORMATION (for U of T Affiliated Sites, omit mailing address)

ADMINISTRATIVE ASSISTANT (if applicable)

ELECTIVE OBJECTIVES

APPROVAL LETTERS

University of Toronto, Department of Medicine
Elective Request Form – Internal Medicine Program