Clerkship Survey for Class of 2011

Please make your selections then press "Submit".

After Submitting the data, please press the "BACK" function on the browser and then hit "RESET" to prepare the questionnaire for the next person.

If you have trouble, contact Allison Innes

Student ID Number (no hyphens): (TAB to next box)

Name (last, first):

E-mail (e.g., ahi2x):

Program enrollment: MD MSTP Generalist (drop down selection box for MSTP and Generalist Program)

Scheduling Preference:

Instructions: You may choose either (1) or (2)
(1) One clerkship (example: I would like to be scheduled for Psychiatry in Period 2)
(2) A location (Here or Away) in a specific period (example: I am getting married in July and want to be scheduled "here" for Period 1, first half)

Schedule:
Each period is 8 weeks long.

Period 1: 5/4/2009-6/27/2009	Period 4: 10/19/2009-12/19/2009
Period 2: 6/29/2009-8/22/2009	break: 12/20/2009-1/3/2010
Period 3: 8/24/2009-10/17/2009	Period 5: 1/4/2010-2/27/2010

Clerkship Information:
More detail about each clerkship can be obtained through the links to the Student Source website below.
Clerkships (by 8 week period):

• Medicine - Ambulatory Medicine (AIM) 4 weeks; General Medicine 4 weeks
• Ob/Gyn & Family Medicine:  4 weeks each (paired)
• Surgery: 8 weeks
• Pediatrics: Newborn 4 weeks; General Pediatrics 4 weeks
• Psychiatry & Neurology: 4 weeks each (paired)

The 5 schedule combinations:

Schedule series #	Period 1	Period 2	Period 3	Period 4	Period 5
100	Medicine	Pediatrics	OB/Family Med	Surgery	Psy/Neuro
200	Psy/Neuro	Medicine	Pediatrics	OB/Family Med	Surgery
300	Surgery	Psy/Neuro	Medicine	Pediatrics	OB/Family Med
400	OB/Family Med	Surgery	Psy/Neuro	Medicine	Pediatrics
500	Pediatrics	OB/Family Med	Surgery	Psy/Neuro	Medicine

Within each schedule (row) above there are variations depending on location and order of rotations within a clerkship period (e.g., Psy can occur before Neuro or Neuro can occur before Psy).

(1) Clerkship	No preference Family Medicine Medicine OB Pediatrics Psychiatry Surgery Neurology
Period:	1 2 3 4 5

...or

(2) Here or Away	No preference Here Away
Period:	1 2 3 4 5
Timing:	No preference 1st half 2nd half

Comments - be brief (25 words or less -- if more your record will be rejected by the program!!!)

What area(s) of medicine are you interested in?

Additonal Questions:

I would like to be considered for a Pediatric rotation at Fairfax: (housing is available)	Yes	No
I have Health Insurance coverage: Remember all students are required to carry health insurance	Yes	No
I would be willing to trade clerkships with a student who has small children to enable them to stay in Charlottesville.	Yes	No
I would be interested in going to Southwest Virginia for Family Medicine or one month of Medicine (Ambulatory Internal Medicine)	Yes	No

	Fairfax	Reston	Sterling	Herndon	Manassas	Alexandria	Vienna	Annandale	Leesburg
There are several Family Medicine and Medicine sites in Northern Virginia but no housing. If you would like to go to Northern Virginia and have a place to stay, check all sites that would be acceptable to you:

For use in housing assignments, are you allergic to:	Yes	No
Pets?
Mold?
Smoke?

During your 3rd and 4th years as medical students you will need an overhead paging (PIC) number. How do you want your name to be announced over the paging system (use the name you go by daily not the one on your driver's license):

Please write out your first and last name phonetically for the page operators (ex. Allison Innes: Al-la-son In-s):

If you have a pager number please enter it (let us know when you get one!)

Thank you for completing this questionnaire.  Schedules will be released beginning of January for all students who expect to start clerkships at the beginning of May 2009 (USMLE Step 1 must be taken before April 22 to be able to start clerkships.).

Submit your answers by hitting this button: