M3 Clerkships - Emergency Medicine Student Elective
Exit Survey
Questions marked with a
*
are required
100%
Demographic Information
Today's Date
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Phone where you can be reached:
Do you plan to apply to our Emergency Medicine Residency?
Yes
No
Contact Information
Last Name
First Name
Middle Name
Street Address
City
State
Zip Code
Email Address
What is your date of birth?
Month
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Birthplace (City, State, Country)
Citizenship
Undergraduate Education
Undergraduate University
Degree(s) Awarded
Graduation Date
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Year
1970
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Medical School Education
Medical School
Location (City, State, Country)
Anticipated Graduation Date
Month
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Year
1970
1971
1972
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1981
1982
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1987
1988
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USMLE Step I Score
USMLE Step II Score (if available)
Requested Elective Information
Check if you have already applied for this elective via VSAS.
Yes
No
Check if you will be applying via VSAS in the next week.
Yes
No
Check if you have submitted your medical school transcript via VSAS.
Yes
No
Check if you are an osteopathic student and are also submitting the pdf application.
Yes
No
Check if you are an international student and are also submitting the pdf application.
Yes
No
If you checked one of the previous 2 boxes, check here if you will be emailing or faxing your transcript to
[email protected]
, 423.778.7677. We must receive this to complete your application.
Yes
No
Requested Elective Dates
We do not approve students outside the UT block dates.
1st Choice Beginning Date
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
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Day
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31
Year
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
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1995
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1997
1998
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2007
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2009
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2011
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2014
2015
2016
2017
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2020
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2022
2023
2024
2025
1st Choice Ending Date
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
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08
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25
26
27
28
29
30
31
Year
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2nd Choice Beginning Date
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2nd Choice Ending Date
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
3rd Choice Beginning Date
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
3rd Choice Ending Date
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
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