Medical Education Pathway Form

Your Information First Name:
Last Name:
Email Address:
Anticipated date of graduation:

Statement of Intent

This should include a brief description of a meaningful personal teaching encounter, either as a student or as a teacher. 400 word limit

Intent:

Proposed area of teaching interest

State whether you have a specific subject area or topic in mind (e.g. anatomy, clinical skills, ethics, etc). Be sure to describe a curricular innovation or improvement that will be the focus of your teaching experience as a participant in the MEP. 400 word limit

Area of interest:

Identify a faculty mentor. If you need assistance identifying a faculty mentor, please contact a member of the Medical Education Pathway Committee.

Mentor's name:

I have discussed my plans for participation in the Medical Education Pathway Program with my mentor.

Yes

No

Have you ever been involved in a case brought before the Honor Board or MSPRB in which a corrective action was deemed necessary? If yes, please briefly describe the outcome, stating whether the issue was successfully remediated and resolved, or is still ongoing with action pending. You do NOT have to discuss the specific issue, just the outcome as described above.

I have discussed my plans for participation in the Medical Education Pathway Program with my advisory dean.

Yes

No

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