Special OB/GYN Student Online Elective Application
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Note: Due to an increasing volume of UT students rotating in Chattanooga, we are no longer able to consider visiting students from institutions outside the US.
Demographic Information
Today's Date
Interested in our Residency program?
Check this box if you plan to apply for our Residency Program.
Contact Information
Date of Birth
Citizenship
Citizenship (Citizenship Country and Visa Status if not a US Citizen. We do not sponsor visas for medical students.)
Undergraduate Education
Undergraduate University
Degree
Graduation Date
Medical School Education
Medical School Name
Medical School City, State, and Country
Anticipated Graduation Date
Type of Degree (DO, MD, MBBS, etc.)
USMLE Step I Score (If not yet available, enter date taken or anticipated date taken.)
USMLE Step II Score (If not yet available, enter date taken or anticipated date taken.)
Elective Application Information
Check if you already applied for this elective via VSAS
Check if you plan to apply via VSAS in the next week
Check if you have submitted your medical school transcript in VSAS
Check if you are an osteopathic student and have/will have submitted our PDF application.
Check if you are an international student and have/will have submitted our PDF application
If you checked either of the last 2 boxes, your transcript must be sent to UTOBGYN@erlanger.org. We must have this to consider your application.
Requested Elective Information
How many OB/GYN electives are you requesting? (Three 4-week rotations are the maximum # that can be approved in total at the Chattanooga Campus.)
Course Names/Numbers/Descriptions
Name and Course # of 1st Choice Elective
Name and Course # of 2nd Choice Elective
Name and Course # of 3rd Choice Elective
Requested Block Dates -- We do not approve requests outside the UT Block Dates. Refer to the UT Student Block Date schedule found at this link:  uthsc.edu/medicine/chattanooga/medical-education/documents/clinical-rotations-calendar-2020-2021.pdf.
1st Choice Beginning Date
1st Choice Ending Date
2nd Choice Beginning Date
2nd Choice Ending Date
3rd Choice Beginning Date
3rd Choice Ending Date
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