CLERKSHIP SCHEDULE FORM Complete the following schedule form and fax it to the Program by the Friday of the first week of the clerkship. Program fax number: 516-463-5177. Student Name:_________________________________________ Date:______________________ Preceptor Name:_______________________________________ Preceptor Telephone:________ Clerkship Specialty:_____________________________________ Clerkship Number:_________ Document the date and hours that you are assigned to work on the following table. Also document any hours that you are making up. Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Week 1 Dates: Week 2 Dates: Week 3 Dates: Week 4 Dates: Week 5 Dates: Any changes to this schedule must be submitted to the program immediately and prior to date/dates changed. All changes must be approved by the clinical coordinator and this form needs to be signed by your designated preceptor. Excused Absences (please list date of absence and make-up date) 1.____________________________________ 2.____________________________________ 3.____________________________________ Student Signature____________________________________________________Date _________ Preceptor Signature__________________________________________________ Date __________
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