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Student Instruction Rotation Request Evaluation of AHEC

Student Rotation Request Form Directions Please fill in the following form if you want AHEC CBE Coordinator to help your community rotation. We will contact you as soon as possible. Participating School: --Select One-- The University of Texas Medical Branch at Galveston * Last Name: * First Name: * Middle Name: Last four digits of SSN: Date Of Birth: Gender: --Select One-- Female Male Ethnicity: --Select One-- American Indian or Alaska Native Asian - India Asian - Korea Asian - Malaysian Asian - China Asian - Japan Asian - Cambodia Asian - Pakistan Asian - Philippines Asian - Thailand Asian - Vietnam Asian - Other Black or African American Hispanic or Latino - Mexican Hispanic or Latino - Puerto Rican Hispanic or Latino - Central American Hispanic or Latino - South American Hispanic or Latino - Other Hispanic or Latino - Cuban Native Hawaiian or Other Pacific Islander White Disadvantaged White Non-Disadvantaged Address: City: * State: * ZIP: Work Phone: Home Phone: Cell Phone: Pager: Other Phone: Fax: Web Site: Email: Briefly describe your request at below (Maximum 4096 characters): Discipline (select all that apply) (Check All:) Allopathic Medicine (MD) Assistants Clinical Laboratory Sciences Clinical Psychology Community Health Worker Dental Public Health Dentistry Food and Nutrition Services Health Administration Health Information Nurse Practitioner Nurse-Midwives Osteopathic Medicine (DO) Other Allied Health Pharmacy Physician Assistant Public Health Rehabilitation Social Work Technicians and Technologists Undergraduate Nurse Specialty (at least select one) (Check All:) Dermatology Familly Practice - Family Medicine Family Practice - Complimentary Alternative Medicine (CAM) Internal Medicine - Allergy Internal Medicine - Cardiology Internal Medicine - Endocrinology Internal Medicine - Gastroenterology Internal Medicine - General Internal Medicine - Geriatrics Internal Medicine - Hematology / Oncology Internal Medicine - Infectious Diseases Internal Medicine - Nephrology Internal Medicine - Pulmonary Internal Medicine - Rheumatology Med / Peds Neurology OB / Gyn Ophthalmology Orthopedics Others Otolaryngology (ENT) Pediatrics - Allergy Pediatrics - Cardiology Pediatrics - Endocrinology Pediatrics - Gastroenterology Pediatrics - General Pediatrics - Genetics Pediatrics - Hematology / Oncology Pediatrics - Infectious Diseases Pediatrics - Neonatology Pediatrics - Nephrology Pediatrics - Pulmonary Pediatrics - Rheumatology Psychiatry Public Health Surgery - Cardiothoracic Surgery Surgery - General Surgery - Neurosurgery Surgery - Oral and Maxillofacial Surgery Surgery - Plastic Surgery Surgery - Urology Other Information Marital Status: --Select One-- Divorced Married Separated Single (never married) Unknown Widowed Education Level: --Select One-- Associate Degree Bachelors Degree DO Masters Degree MD PA PhD Post Graduate Residency * indicates required field.

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