Name: *Select Student Name Altheimer, Alicia Austin, Richard Barfield, Andrew Bauman, John Becker, Amanda Betzle, Christopher Boucek, Lisa Canaday, Dian Chandra, Sidharth Cheatham, Terah Dawood, Moiz Day, Rachel Dodia, Neal Feller, Cathy Galanos, Kelly Grimm, Trenton Hagene, Michelle Haryani, Anand Henkle, Benjamin Hiatt, Elizabeth Jimenez, Monica Johnson, Kevin Juvinall, Douglas Keeler, Aisha Ken, Jonathan Ken, Kimberly Khan, Imran Koch, Craig Kulacz, Jeremy Leverenz, Ashley Malvik, Natalie Mathews, Dionna Mayfield, Allison McKenna, Katherine Meyer, Bria Michael, Alex Michaels, Jason Miedema, Christopher Miksanek, Zachary Miller, Peter Nester, William Parke, Jacob Patel, Raunak Patel, Sonal Raab, Joseph Rabideau, Amanda Rebeiro, Sumi Reid, Taylor Roloff, Carolyn Ros, Sara Rosenkrans, Daniel Ryan, Daniel Sadowski, Daniel Sanserino, Kathryne Schmucker, Drew Simon, Kevin Spencer, Lauren Swong, Michael Tennill, Robert Thompson, Kirk Urish, Ashley Varney, Brittany Varney, Jacob Wakid, Christopher Washington, Vance Weitzel, Laura Yanik, Susan Yoon, Kristopher Yu, Xin Zubairu, Josiah zzTest Advisor: Tom Ala, MD Janet Albers, MD Michelle Alepra, MD Joseph Baima, MD Amber Barnhart, MD Joseph Basler, MD Craig Batterman, MD Beau Batton, MD Gregory Bennett, MD Jeffery Bennett, MD Careyana Brenham, MD Lucinda Buescher, MD Reginald Bulkley, MD Ted Clark, MD Alan Deckard, MD Jonathan DelaCruz, MD Mary Dobbins, MD Gary Dunnington, MD Myto Duong, MD Rodger Elble, MD, PhD Stuart Frank, MD Keith Gabriel, MD Christopher Gleason, MD John E. Godwin, MD David Griffen, MD Susan Hingle, MD Jason Kegg, MD Lynn Kink, MD Janak Koirala, MD Regina Kovach, MD Harald Lausen, DO Scott Long, MD Lauri Lopp, MD Tracy Lower, MD Fritz Lower, MD Chris McDowell, MD Patrick McKenna, MD Wesley McNeese, MD Tracy Milbrandt, MD Michelle Miner, MD Robert Mocharnuk, MD John E. Murphy, MD Erica Nelson, MD Linda Nordeman, MD Matthew Peecher, MD Michael Pranzatelli, MD Mark Puczynski, MD Don Ramsey, MD David Resch, MD Gary Rull, MD Leonard Rybak, MD, PhD Laura Salazar, MD Hilary Sanfey, MD Andrew Sherrick, MD Souhail Siddique, MD Ross Silverman, JD Stephen Soltys, MD Nicole Sommer, MD David Steward, MD Ted Sunder, MD Cynthia Thomas, MD Christine Todd, MD Laura Vargas, MD Andrew Varney, MD Zeng Wang, MD, PhD Yahia Zeino, MD Elvin Zook, MD
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 Choose Pathway Family & Community Medicine Internal Medicine Obstetrics & Gynecology Pediatrics Psychiatry Population Health Surgery: General Surgery Surgery: Otolaryngology/Head & Neck Surgery Surgery: Orthopedic Surgery Surgery: Plastic Surgery
Undeclared
Activity or Course Title
Start Week
Duration
AM/PM Full time, Extended
4 weeks
Select CCX Week 3 4 5
2 days
35
2 weeks
weeks
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
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)
This registration request meets the requirements for the fourth year elective program as stated in the elective policy for the Class of 2013.
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Elective Advisor Signature:
Date:
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