All students planning to step of the MD curriculum sequence are required to complete this form in order to track academic progress.
* indicates required fields.
Student ID *
Current Year *
Reason for stepping out *
Dual Degree: MD/PhD
Dual Degree: MD/MBA
Dual Degree: MD/MPH
Dual Degree: MD/JD
Dual Degree: MD/MS
Dual Degree: Other
Official University Leave of Absence
If you selected 'Other' for any of the categories above please explain your reason for stepping out
Academic Year *
Academic Year *
Expected Graduation Year *
All students are required to discuss their intention to step out with their Advising Dean, assigned Educator-4-CARE faculty and the information will be shared with the Assistant Directord for Medical Student Research and Scholarship to ensure that academic requirements have been met and a plan for re-entry into the MD Curriculum is established if applicable.This discussion can take place in person, by phone or over email but must take place PRIOR to the submittal of this form.
I acknowledge that I have discussed my plans with my Advising Dean and they are in support of my stepping out of the MD curriculum.
Academic Advising Dean Name *
I acknowledge that I have discussed my plans with my E4C faculty and I will require a 'Clinical Skills Maintenance Plan' during my time out of the MD curriculum sequence.
I acknowledge that I have discussed my plans with my E4C faculty and I will NOT require a 'Clinical Skills Maintenance Plan' during my time out of the MD curriculum sequence.
E4C Faculty Name *
Please skip. Do not fill this out.