Observership Experience Form

This form is required for MS1 and MS2 students who have already arranged an observership or shadowing experience with a faculty member or physician and have confirmed the start and end dates. Completing this form allows our office to gather the information needed to determine any onboarding or credentialing requirements prior to your experience. Students should submit the form only after finalizing their schedule with the supervising physician.

Any questions about your request can be directed to cim@utrgv.edu.

Required Information

Please provide the following required information and then submit the form.

Full Name (Required)

Email (Required)

Student ID (Required)

Year (Required)

Specialty Interest (Required)

Attach CV Document

Full Name of Faculty Member Intended to Shadow (Required)

Faculty Member/Community Faculty Email Address (Required)

Name of Shadowing Site (Required)

Shadowing Site Full Address (Required)

Start Date (Required) Format: mm/dd/yyyy

End Date (Required) Format: mm/dd/yyyy

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Observership Experience Form

Required Information

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Edinburg

Harlingen

Brownsville

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