Student:

1. Fill out the first five lines on validation form below
2. Ask the attending or senior resident who worked up patient with you to complete the rest of the form
3. Turn in form to the Medicine Clerkship Office or place in Medicine Clerkship Box in Medicine Office on 6th floor of University Hospital (one form needs to be completed for each write-up and returned to the office by the end of the clerkship)

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VALIDATION FORM

Student Name:_________________________________________________

Write-Up # _______

Patient Initials:___________

Date Patient Seen:___________________

Problem (s):_____________________________________________________________

I validate that this student saw the above patient with the above listed problem while they were working with me.

_____________________________________________________  Physician's Signature

_____________________________________________________  Physician Print Name

______________________________  Date