Internal Medicine Rotation Change Request

*NOTE* This form is intended for Internal Medicine Residents only Complete this form to request a rotation change during a given block.

"*" indicates required fields

Resident Name*

First Last

Program Year*

PGY1

PGY2

PGY3

PGY4

Resident Email*

Rotation Information

Please add the information on the rotation you wish to add/remove

Rotation I would like to change out of:*

Service, Site

BLOCK #*

Reason for Change

Include the reason you wish to change service. For example, wish to drop service A as my career plans have changed or, once in a lifetime rotation available at x site I would like to pursue.

Service Contact- removing service*

Find service contact info here: https://entrada.med.ubc.ca/community/departmentofmedicine:contacts Usually this is the admin or individual under the contact list column.

First Last

Service Contact Email - Removing service*

Rotation I would like to add:*

Please use format service, hospital, block (e.g. Nephro, RCH, Block 5) For OOP and research blocks, no site required.

Service Contact - Adding service

CTU service chief are the CMR's for each site, Research, OOPs, BC Electives are to be sent to the Program Coordinator, Melissa Nightingale, other rotations see the contact list in Entrada: https://entrada.med.ubc.ca/community/departmentofmedicine:contacts

First Last

Service Contact Email - adding service*

Vacation Dates:*

Use this section to inform service of existing vacation dates or to request vacation during the service. If it is a new vacation, please ensure you adhere to the vacation guidelines for time away from service, etc.

Yes

Vacation Start Date*

Vacation End Date*