School of Medicine Semester 2 Supervisor Declaration form

Please complete the below details as confirmation of your availability to supervise Deakin University School of Medicine Semester 2 exams.

Required fields are marked with an asterisk (*).

Your details

Title

Your first/given name *

Your surname *

Address line 1 *

Address line 2

Suburb/Town *

State *

Postcode *

Mobile phone number *

Deakin/Personal email address *

Deakin staff number (if known)

Your availability

Please select your availability *

I am available (please select the dates and time below)
I am not available for these exams but I would like to remain on the list for future exams
I am not available for these exams and I no longer wish to supervise Deakin exams

Campus location * (be careful when completing your campus location. Please only choose AAA if you currently are engaged as a AAA Supervisor)

Burwood
Geelong
Warrnambool
Ballarat
Ararat

Burwood AAA
Geelong AAA
Warrnambool AAA
Ballarat AAA
Ararat AAA

Conflict of interest

By submitting this form I declare that (in relation to conflict of interest) *
I am not enrolled as a current student at Deakin University.

I am not a family member or related to any of the student(s) whom I will be supervising.

I am not a direct employee of any student(s) whom I would be expected to supervise.

I have reported all potential conflicts of interest.

Yes
No
Not applicable - I do not have any Conflicts of Interest

School of Medicine Semester 2 Supervisor Declaration form

Your details

Your availability

Available dates and times

Conflict of interest

Domestic student

International student

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