Southern Illinois University School of Medicine

Class of 2013


Elective Scheduling Requests for July 9, 2012 - May 17, 2013

Name:       Advisor: 


Wk# -  Date

Wk# -  Date

Wk# -  Date

Wk# -  Date

1 - Jul-09, 2012

14 - Oct-08

27 - Jan-07

40 - Apr-08

2 - Jul-16

15 - Oct-15

28 - Jan-14

41 - Apr-15

3 - Jul-23 (CCX)

16 - Oct-22

29 - Jan-21

42 - Apr-22

4 - Jul-30 (CCX)

17 - Oct-29

30 - Jan-28

43 - Apr-29

5 - Aug-06 (CCX)

18 - Nov-05

31 - Feb-04

44 - May-06

6 - Aug-13

19 - Nov-12

32 - Feb-11

45 - May-13

7 - Aug-20

20 - Nov-19  (Thanksgiving)

33 - Feb-18

Grad: May 18, 2013

8 - Aug-27

21 - Nov-26

34 - Feb-25

 

9 - Sep-03

22 - Dec-03

35 - Mar-04 (Doc)

 

10 - Sep-10

23 - Dec-10

36 - Mar-11

 

11 - Sep-17

24 - Dec-17 (Holiday)

37 - Mar-18

 

12 - Sep-24

25 - Dec-24 (Holiday)

38 - Mar-25

 

13 - Oct-01

26 - Dec-31

39 - Apr-01

 

Your Neurology Clerkship rotation has already been selected and other requests will work around that course.  Also, in the spaces below, please note any SPECIFIC TIME REQUIREMENTS, i.e. clerkship deferrals/remediations that you have to make up, Pending Off-Campus dates that you are sure of, Individually-Designed and Research Electives, and Vacations.  Use the Week # and Date guide above to list time requirements in this space.  Do not # these as priorities.

Using the lines provided next to the priority numbers, list IN ORDER OF PRIORITY, not chronological order, those catalog electives you wish to take along with the length of time desired in weeks. (See completed example form copied on pink paper.)


Program Selection (Choose One):

Specialty Pathway

Undeclared


Activity or Course Title

Start Week

Duration

AM/PM Full time, Extended

Neurology Clerkship

4 weeks

* Select your Neurology Rotation
Senior CCX

2 days

* Select your CCX week
Doctoring

35

2 weeks

Full-time 2 weeks

  weeks

  weeks

  weeks

  weeks

  weeks

  weeks

  weeks

 

Priority # Course Number - Course Description - # weeks
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Please provide any other notes or information that you would like to have considered when your schedule request is entered:

 This form must be submitted by Friday, April 20, 2012.


CHECK YOUR NUMBERING.  You can only have one 1st priority, one 2nd priority, etc.  Forms with numbering errors may cause a delay in scheduling your courses.  Course numbers ending with:  1 indicates half-time mornings only; 2 indicates half-time afternoons only; 3 indicates full time; and courses ending in a 4 indicates Thursday afternoons (extended).

NOTE:  Before clicking on the "submit" button,

please print a copy of this form!

 

  

 

Don't forget to submit the form!!

 

 

 


Contact Us:

Chris Reavis  (Curriculum Information)
Jean Afflerbach
(Web Page)

Copyright 2012 [Southern Illinois University, Board of Trustees]. All rights reserved.
Revised: April 18, 2012

This registration request meets the requirements for the fourth year elective program as stated in the elective policy for the Class of 2013.


 

Student Signature:

______________________________________________________________

Date:

_______________________

 

Elective Advisor Signature:

______________________________________________________________

 

Date:

________________________