SOP - CO-CURRICULAR ACTIVITY (Non-Patient Care) DOCUMENTATION FORM

This form is completed at the conclusion of the co-curricular event and submitted via the ePortfolio portal (CORECompMS) to Dr. Simi Gunaseelan no later than 5 p.m. the following business day.

STUDENT NAME: STUDENT NAME: * First Last
STUDENT EMAIL *
Graduating Class *

Graduating Class Class of 2024 Class of 2025 Class of 2026 Class of 2027
Cohort *

Cohort P1 P2 P3 P4
Co-curricular Event Date Co-curricular Event Date * / MM / DD YYYY
Is event associated with student organization? *

Is event associated with student organization? Yes No
Associated Student Organization Name *
Co-curricular Event Name: *
If other, list Co-curricular Event Name: *
Event Facility Name: *
Event Street Address: *
Event City: *
Description of Event: *
Record the time spent in the co-curricular event

Time in: Record the time spent in the co-curricular event

Time in: * : HH MM AM/PM
Time Out: Time Out: * : HH MM AM/PM
Total Time Spent: *
Record all activities performed within the co-curricular event: *
Officer Name *
Officer Title
Upload image of signed completed paper copy of the Co-curricular Activity Non-Patient Care Documentation Form. *

Attach Files
Comments (Reflect any concerns associated with this event):
Select the level achieved via the co-curricular activity (Select all that apply):
Note: If Level 2 is selected, then Level 1 MUST also be selected.
A description of each of the following Activity Levels is provided under the Co-curriculum section of the Student Handbook. *

Select the level achieved via the co-curricular activity (Select all that apply):
Note: If Level 2 is selected, then Level 1 MUST also be selected.
A description of each of the following Activity Levels is provided under the Co-curriculum section of the Student Handbook. Level 1: I participated in this experience (evidence provided by submitting a complete documentation form) Level 2: I will reflect on this experience by writing a guided reflection
The activities from this co-curricular event meets the following Educational Outcome(s) of ACPE Standards 2016 (please check all that apply):
A description of each of the following Educational Outcome is provided under the Co-curriculum section of the Student Handbook. *

The activities from this co-curricular event meets the following Educational Outcome(s) of ACPE Standards 2016 (please check all that apply):
A description of each of the following Educational Outcome is provided under the Co-curriculum section of the Student Handbook. 1.1. Learner 2.1. Caregiver 2.2. Manager 2.3. Promoter 2.4. Provider 3.1. Problem Solver 3.2. Educator 3.3. Advocate 3.4. Collaborator 3.5. Includer 3.6. Communicator 4.1. Self-aware 4.2. Leader 4.3. Innovator 4.4. Professional