RETURN ALL COPIES TO:

The University of Oklahoma

College of Medicine, School of Community Medicine
Office of Academic Services
4502 E. 41st Street
Tulsa, OK 74135-2512
Phone: 918-660-3504/Fax: 918-660-3090
APPLICATION FOR OBSERVATION
(Not for international applicants)
The University of Oklahoma
College of Medicine, School of Community Medicine

Section I: To be completed by student.

Name:__________________________________________ Institution:_______________________________________
Address:_______________________________________ Address: ________________________________________
_______________________________________________ ________________________________________________
Telephone #:____________________________________ ________________________________________________
E-Mail:_________________________________________ Contact Person:___________________________________
Expected date of graduation:______________________ E-mail:__________________________________________
Current Training Level:__________________________ Telephone #______________________________________
Total amount of time planned at the College of Medicine, School of Community Medicine (# of weeks)__________

Observation Experience Applying For Department Requested Dates

_________________________________________ _________________________________ ______________________
_________________________________________ _________________________________ ______________________

Section II: To be completed by Dean's Office of student's school.

The above named student is in good academic standing at this institution as of the rotation dates requested.
Personal health coverage (is) (is not) in effect away from this school.
This student is authorized to participate in the above stated observation. An evaluation form (will) (will not)
be required.

Signature:________________________________________ Title:___________________________________________

Section III: To be completed by Department, The University of Oklahoma, College of Medicine, School of
Community Medicine The above observation is approved as requested.

Name:___________________________________________ Title:____________________________________________

Signature:________________________________________ Department:_____________________________________

The student should report to: Person:________________________________________________________________

Place:_____________________________________________ Time:___________________________________________
Telephone #:______________________________________ E-mail __________________________________________

Section IV:
The above observation is approved as requested. Approved with the following changes

__________________________________________________ ___________________________________________
Office of Academic Services _____________________________________________________
The University of Oklahoma _____________________________________________________
College of Medicine, School of Community Medicine 1.