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 *

First

Last

Email *

Phone *

Matriculation Year *

Anticipated Graduation Year *

Planned Exit Date (Month/Year) *

Anticipated Re-Entry Date (Month/Year) *

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

On campus

Away from campus

If away from campus, please indicate location

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

Yes

No (if no, please visit http://www.stanford.edu/dept/som_ome/stepoutform.fb to complete the form)

Please provide a brief narrative description of your reason for exit and activities during your time away. *

Please provide a brief narrative description of your plan for maintaining your clinical skills while away from the MD curriculum. *

Each student should check in with their E4C mentor (or other identified clinical skills mentor) at a mid-point during their time away (or, for leaves of greater than one year, every six months) to review clinical progress, identify learning goals, and reconfirm clinical skills plan. Please indicate below an estimated date(s) for check-in(s) with your mentor: *

Please provide a brief narrative description of your plan for refreshing your clinical skills before re-entry into clinical clerkships. This may include completion of Practice of Medicine Q6 or another intensive clinical skills experience or assessment. *

Practice of Medicine INDE 206 (Q6) Completion *

Completed

Not completed

Completion/Anticipated Completion Date *

E4C Faculty Name *

E4C Faculty Approval *

I acknowledge that I have discussed my plans with my E4C faculty and they are in support of my plan.