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Rural Clinic

Checklist

You must submit this checklist and all other course requirements within 7 days of completing this rotation. If all items are not received by the 7th, points will be deducted from the final grade.  You may print this out for your own record.

*Denotes required fields
*First Name	*Email
*Phone	*Alternate Phone/Pager
(Enter your 10 digit number without other characters; i.e. no dashes, no parenthesis).

		Check yes if completed
*Student Performance Evaluation Form		Yes	No
*Site Evaluation Form		Yes	No
*PowerPoint Case Presentation Submit via email		Yes	No
*AHEC Forms Return to AHEC coordinator		Yes	No
*Videoconference Evaluation Form		Yes	No
Topic:
Date:
*Other Approved AHEC Program   e.g. Kids in Health Careers		Yes	No
Title:
Location:
Date:

Additional Comments: