ࡱ> ikh_ 0Bbjbj 4Rbb* 008J4~LVUUUUUUU$EXZHUQy@U=V@ @ @ RU@ U@ @ N6P"2Us(Q0USV0VR$?[r?[`2U?[2UZ@@ S49UUFV?[0 P:  ,'E9) 'D3D7'F B'(H3 CDJ) 'D7( H 'D9DHE 'D5-J) (1F'E, 'D*/1J( 'D31J1J .'1, 'D3D7F) SULTAN QABOOS UNIVERSITY College of Medicine & Health Sciences Clinical Elective Program (Overseas) 'B1'1 H *9G/Q D E C L A R A T I O N #F' & & & & & & & & & & & & & & & & & & & & & & & & & & & 'DEHB9 #/F'G #B1 ('D"*J: I, & & & & & & & & & & & & & & & & & & & & & the undersigned hereby declare that; B1#*O H AGE* 'D*9DJE'* H 'DDH'&- 'D*F8JEJ) D(1F'E, 'D*/1J( 'D31J1J .'1, 'D3D7F) H 'D0J #J6'K H6-N DJ EF B(D 'DE3$HD 9F 'D(1F'E,. I have read and understood the guidelines and regulations of the Clinical Electives program which have also been explained to me by the Program Coordinator. #.0*O 'DEH'AB) EF H'D/JQ/HDJQ #E1J DDBJ'E (G0' 'D(1F'E, .'1, 'D3D7F)  AJ & & & & & & & & & & & & & & & .. ((D'/) AJ & & & & & & & & & & & & & & & .. (E3*4AI / ,'E9)) DE/) & & #3'(J9. I have taken the necessary permission from my parents to do my Clinical Electives outside Oman, in & & & & & & & & & & & & & & & .. (Country) at & & & & & & & . & & & & & & (Hospital/University) for a period of 8 weeks. D/J CD 'DE9DHE'* 'D61H1J) -HD 'DCDJQN) / 'D,'E9) / 'DE3*4AI 'D*J 3#CHF ED*-B'K (G' #+F'! A*1) 'D(1F'E,. I have all the necessary information about the college/university/hospital to which I will be attached during my Clinical Elective period. 3#CHF #F' 'DE3$HD 9F /A9 13HE 'D%B'E) 3H'! C'F* ('D*F3JB E9 EC*( 'D*/1J( 'D31J1J #H (*1*J(G' 4.5J'. I will be fully responsible for payment of the accommodation charges whether it is arranged by the Clinical Elective Office or by myself. 3#CHF #F' 'DE3$HD 9F /A9 13HE 'D*3,JD  FAB'* 'D3A1 H 'DE9J4)  #H #J 13HE '.1I E*9DB) ('D(1F'E,. I will be responsible for full payment of the registration fees, utility bills, or any other charges related to my overseas Clinical Elective program. 3#CHF #F' 'DE3$HD 9F 'D-5HD 9DI CD 'DH+'&B 'D61H1J) DD3A1  E+D ,H'2 'D3A1  'D*#4J1)  'D*#EJF 'D5-J  'D*B'1J1 'D7(J) ... 'D.. I will be responsible for obtaining all the necessary travel documents for my trip, such as renewed passport, visa, health insurance, medical reports, etc. 3#D*2E ('DDH'&- H 'D*9DJE'* DDE$33) H 'D(D/) 'DE6JA) H ,'E9) 'D3D7'F B'(H3. I will obey the rules and regulations of the host institution/country and that of the SQU. #B1 (#FFJ 9DI %3*9/'/ *'E D*B/JE 916 9F 'D.(1'* 'D*J 3#C*3(G' EF G0' 'D(1F'E, AJ -'D) %0' E' 7D( EFJ 0DC. I acknowledge that I fully prepared to make a presentation on the experience gained from this program if so requested. #B1 (#FFJ AJ -'D) 5-JQ) ,J/) H DJ3* D/J #J E4'CD 5-JQ) *EF9FJ EF 'D3A1 #H *916 5-) 'D".1JF DD.71. I am in good health and have no medical conditions that will prevent me from traveling and will not pose any risk to my health or jeopardize the health of others during my elective period. AGE*O 'D41H7 H 'D%D*2'E'* 'DE0CH1G #9D'G ('DC'ED H #J .1B #H 9/E '3*JA'! D#J EF G0G 'D41H7 #H *9DJE'* 'D(1F'E, B/ J$/J %DI *#.1 *.1,J. I " $ X n p * , z ֵ姛ssgsVggHghNx+hNx+CJZ_H aJ!hNx+hNx+6CJZ]_H aJhNx+hNx+CJZaJhNx+hNx+6CJ]aJhNx+hNx+6CJZ]aJhNx+hNx+CJaJhNx+hNx+CJ\aJhNx+hNx+CJZ\aJhNx+hNx+5CJ\aJ$hNx+hNx+6>*CJZ]_H aJhNx+hNx+6>*CJ]aJhNx+hNx+5CJZaJhNx+hNx+5CJaJ*^$ X n p , $ & F  hA$]a$gdNx+$  A$]a$gdNx+   ]gdNx+$  A$]gdNx+$  ]a$gdNx+gdNx+gdNx+$a$gdNx+$a$gdNx+ z tmU$ & F  hA$]a$gdNx+$  ]^`a$gdNx+ & F  ]^`gd-$  A$]^gdNx+$ & F  hA$]gdNx+$  A$]^`gdNx+$ & F  ]^`a$gdNx+ rVj*,^X*,$~ Vbƻ}h]R]R]R]h#~hYxCJaJh#~h RCJaJ(jh#~hYxCJUaJmHnHuh#~h|0]CJaJo(h#~h RCJZaJo(h#~h|0]CJZaJo(hjGCJZaJo(hjGhjGCJaJhNx+hjGCJaJhNx+CJaJh|0]CJZ_H aJo(hNx+hNx+CJZ_H aJhNx+hNx+CJZaJhNx+hNx+CJaJ tVjl,^`kN$ & F  ]^`a$gdNx+$ & F  hA$]a$gdNx+$  ]^`a$gdNx+$ & F 7 7;]^7`;a$gdNx+$ & F  hA$]gdNx+$  ]^a$gdNx+$ & F  ]^`a$gdNx+`Z,nqiT$ & F  hA$]gdYx & FgdYx$ & FhA$gd RgdjG$ & F  ]a$gdjG$ & F  hA$]gdjG$  ]^`a$gdNx+$ & F  ]^`a$gdNx+$ & F  hA$]a$gd|0] ln./00h0J1l33.404555556667ѽѲݰѧљݑ}rg^Rrh;ho|yCJaJo(ho|yCJaJo(hNx+ho|yCJaJho|yCJZaJo(ho|yho|yCJaJo(ho|yCJaJhNx+CJaJhNx+hNx+CJZ_H aJh-CJZaJUh#~CJZaJo(h#~CJZaJhV?CJZaJo(hNx+hNx+CJZaJhNx+hNx+CJaJhNx+hjGCJaJhNx+hjGCJZaJn//N1l3n3pS$ & F  ]^`a$gdYx$ & F  hA$]gdYx$  ]a$gdNx+$ & F  ]^`a$gdYx$ & F  hA$]gdYx$  ]^`a$gdNx+$ & F  ]^`a$gdYxhave fully understood the above terms and conditions and any breach or non-fulfillment of any of these conditions or the regulation of the Clinical Elective program may result in delay of my graduation. #B1 (#FFJ 9DI /1'J) *'E) (#FG D' J-B DJ EGE' C'F* 'D81HA 9/E '3*CE'D 'D*/1J( %D' AJ -'D) 7'1&) H 'D*J J,( #F *+(* ('D#/D) H 'DH+'&B 'D*J *(11 9/E %3*CE'DJ DD*/1J(. H EF +E A%F 'DCDJ) 3*-CE 9DI 'D-'D) H *(D:FJ ('DB1'1. I note that under no circumstances I am allowed to discontinue elective attachment in an overseas institution, except in a dire emergency situation, for which documentary evidence will be produced, upon which, College will judge the situation and inform me accordingly. %0' B11* 'D9H/) H 9/E '3*CE'D 'D(1F'E, E.'DA' (0DC *9DJE'* 'D*/1J(  A#F' E/1C CD 'D%/1'C DD*'DJ: If I decide to return home against the clinical elective programme regulations, I am fully aware of the following: E3$HD 'D*/1J( 'D31J1J DF JCHF E3$HD'K 9F *1*J( #H *F3JB */1J( (/JD. The Clinical Elective Office will not be responsible for arranging alternative placement either overseas or locally. 3J*E E7'D(*J (%1,'9 C'A) 'D13HE ('D%6'A) %DI 'D*0'C1 'D*J HA1* DJ EF B(D 'D,'E9). I will be required to refund the complete financial assistance including tickets provided by the University for the Elective Course *-*A8 'DCDJ) (-B A16 9BH('* %6'AJ) H 'D*J *B11 EF B(D 'DD,F) 'D*FAJ0J). The College also reserves the right to levy additional penalty decided by an Executive Committee. (E' #F 'D*/1J( 'D31J1J ,2! EF (1F'E, 'D7( ('DCDJ) A%F 9/E %3*CE'D 'D(1F'E, 'D31J1J (F,'- 3J916FJ D%-*E'D'* *EF9 %F,'2J 'D%E*-'F 'DFG'&J (F,'-. Since clinical electives is one of the components of MD program in the College, failure to complete it successfully, will jeopardize me fulfilling to sit for final MD examinations. %0' /9* 'D-',) A9DJ 'D*H'5D E9 'DE3$HD 9F 'D*('/D 'D7D'(J. Should a need arises, I must directly communicate with concerned officials. ---------------- --------------------------- --------------------------------------------------- '3E 'D7'D( E9 'D1BE 'D,'E9J *HBJ9 'D7'D( 'D*'1J. Date Signature of Student Name & ID No. of Student ---------------- --------------------------- --------------------------------------------------- '3E HDJ 'D#E1 *HBJ9 HDJ 'D#E1 'D*'1J. 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