Your last name
Your first name
Your email
I am a PURCH student
FCE Course Title
Has this FCE been offered previously?
-- Select an option --
No | This is a BRAND NEW experience (FCE)
Yes | This submission is BAYSTATE version of a previous FCE
Yes | This experience was originally offered as a STUDENT DESIGN
Yes | This submission is a GENERAL UPDATE to an existing FCE
Supervisor Name [include degrees]
Named supervisor is a member of the UMMS Faculty
Named Supervisor Profile URL | copy from https://profiles.umassmed.edu/search/
Named Supervisor has agreed to supervise this experience
Supervisor email
Supervisor phone
Supervisor mailing address
Supervisor Department
-- Select an option --
Select Supervisor Department Affiliation
Anesthesiology & Perioperative Medicine
Dermatology
Emergency Medicine
Family Medicine & Community Health
Medicine
Neurobiology
Neurology
Neurosurgery
Obstetrics & Gynecology
Ophthalmology & Visual Sciences
Orthopedics & Physical Rehabilitation
Otolaryngology
Pathology
Pediatrics
Psychiatry
Radiology
Radiation Oncology
Surgery
Urology
--------------------------------
My supervisor's department isn't listed | see below
FCE Support Personnel
FCE Information and Description
Experience Location (include contact information and room numbers)
Interdisciplinary
-- Select an option --
Is this an INTERDISCIPLINARY experience?
Yes | see department list below
No | This FCE does not cross disciplines
Interprofessional
-- Select an option --
Is this an INTERPROFESSIONAL experience?
Yes | see list below
No | This FCE does not involve other health professionals
UMass Chan Competencies | <ctrl+click> all that apply
competencies
Physician as Advocate
Physician as Communicator
Physician as Person
Physician as Problem Solver
Physician as Professional
Physician as Scientist
Physician as Healthcare System Navigator
Experience Description (you may upload further information below)
Experience Objectives (eg, By the end of this session student will be able to...)
Evaluation Type | <ctrl+click> all that apply
-- Select options --
Attendance
Clinical Performance
Demonstration of Skills
Exam
Journal
Narrative Assessment
Oral Presentation
Participation
Portfolio-based
Practical (lab)
Reflection
Research or Project Assessment
Other | see explanation below
Select ONE Flexible Experience week during which your FCE will take place.
for two week experiences, type the second term information in the text box below
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Select one FCE week
1A | FE1 | June 6, 2022 ‐ June 10, 2022
1B | FE2 | July 11, 2022 ‐ July 15, 2022
1C | FE3 | July 18, 2022 ‐ July 22, 2022
2A | FE4 | September 26, 2022 ‐ September 30, 2022
2B | FE5 | October 3, 2022 ‐ October 7, 2022
2C | FE6 | November 7, 2022 ‐ November 11, 2022
3A | FE7 | January 30, 2023 ‐ February 3, 2023
3B | FE8 | March 6, 2023 ‐ March 10, 2023
3C | FE9 | March 20, 2023 ‐ March 24, 2023
Additional Comments or Proposal Information
Submit proposal to FCE Leadership