Senior Radiology Clerkship Preference Form

Your Name: _______________________________

DAYS I WILL MISS: ________________________________

A.      Please place a numeral (1 through 9) against each of the Electives on the list below in order of your preference (1 for the most desired and 9 for the least)

                                       Abdominal Imaging at University or Wishard

                                      (Fluoro, US, CT)

                                       Chest Radiology at University or Wishard

                                       Ortho Radiology at Wishard ER only

                             ____  Interventional at Wishard only

                                  _  Mammography at Wishard or University

                                _     Neuroradiology at University

                                       Nuclear Medicine at University only

                                _    Pediatric Neuroradiology at Riley MRI

                                       Pediatric Radiology at Riley

B.      Will you be fulfilling your Level III Communication Competency in radiology this month?  _____yes           _____no  

          C.      Your residency plans:____________________________

Please return this form by email or fax to me at 944-2920