University of Tennessee - College of Medicine
Department of Family Medicine
M3 Clerkship Placement Survey for Academic Year 2008-2009

If you wish to return your form via US mail, please print the "printer-friendly" version.
Return your completed form to the address indicated at the bottom of the form.

   
Statewide and surrounding states		    
and surrounding counties		    
and surrounding counties

**Completed forms for Knoxville and Chattanooga will be forwarded to their respective clerkships.

Course Structure:  Family Medicine Clerkship rotation consists of two required core educational blocks (4 weeks each).  For the most part students will be assigned to one of the UT Family Medicine residency training centers for one block.  During the other block students will be assigned a community based Family Medicine clinical faculty (approved preceptor) office.  It is possible that you can be assigned  to a comprehensive community based site for the entire 8 weeks, including distant sites where housing relocation would be required. The following information, if provided, will be taken into consideration when assignments are being made.  However, the final assignments will be made by the department based on location, clinical faculty, and appropriate training environment availability.  We do ask your cooperation in providing the following basic information including special educational requests.

Section I
  
  
Memphis Address:

Hometown:
 

    Single    Married
      Yes    No

If yes, explain:  
Section II

Review and complete the following if you have elected Course FME1-3001/F: Memphis

Examples of communities where approved training sites exist that are assigned through UT Memphis - FME1-3001/F (subject  to  scheduling  availability):  Including F.M. Residency Training Centers/Hospitals in Jackson (housing/transportation stipend available for Jackson only) (Jackson/Madison); Memphis (St. Francis):

Tennessee
*Bartlett  Dickson  Jackson   Livingston   Newport   Union City
 Bristol  Fayetteville  Jamestown   McKenzie   Selmer   Waynesboro
 Cordova  Franklin  Jellico *Memphis   Sewanee   Winchester
 Columbia  Gallatin  Jefferson City *Munford   Shelbyville  
 Cookeville *Germantown  Johnson City   Murfreesboro   Sparta
*Collierville Greenville  Lawrenceburg   Nashville   Tullahoma  
Covington Huntingdon  Lexington
 
Arkansas Mississippi
**Pine Bluff *Senatobia
*Forrest City *Southaven
**Jonesboro   New Albany
**Little Rock   Olive Branch
**Fayetteville

*Considered as Memphis area
 ** A few training sites provide free housing, provided you need to relocate.

Section III

Please rank in order of preference where you would like to serve the clinical phase of the clerkship, including residency training centers and community faculty offices. Feel free to suggest the name(s) of potential faculty physician-preceptor. Contracts with clinical faculty for the purpose of student placement must be handled by the Department of Family Medicine. Independent agreements initiated by students with preceptors will not be honored.

  Most Preferred Location (Town/City) List Suggested Family Medicine Faculty/Preceptor (if known, not required)
    1. (First Choice)
    2. (Second Choice)
    3. (Third Choice)
Section IV

What other information would you like us to consider in finalizing your assignment, including needs for housing?

It will be the students' responsibility to keep the Department of Family Medicine informed of any changes in address, telephone number, and/or training site preferences.

   

Mail or email to:

Marilyn Ward
Administrative Specialist, III/Coordinator
711 Jefferson Avenue, Suite 137
Memphis, Tennessee 38105
Telephone: (901) 448-6032  |  Email: mward9@utmem.edu

Form revised January 10, 2008:mgw