Clinical Skills and Acquisition Maintenance Plan

Please complete the form below once a plan has been developed in coordination with your E4C Faculty.

* indicates required fields.

Name *








During my time away from the required MD curriculum, I will be: *


Have you completed the "Intention to Step out of the MD Curriculum" form? *





Practice of Medicine INDE 206 (Q6) Completion *



E4C Faculty Approval *