Vacation and Electives Request Form

Michael Salim
Resident Name:___________________________ Academic Year: PGY2
x PGY3

1 I prefer to have:
x one full month of vacation

two blocks of 2 weeks vacation

2 Please enter your preferred vacation time starting from most to least preferred:
Remember to specify the blocks by 2 weeks(it can either be the first or the last 2 weeks of a month)

a. January 2022

b. March 2022

c. May 2022

3 Please select your top 5 electives you would like to have for next year:
Put a specific number on the box next to the elective name ( 1-most preferred…5-least preferred )

GI Rheumatology

Cardiology 5 Nephrology

1 Endocrinology 3 Neurology

4 ID Primary care

2 Pulmonology Palliative Care

Hem/Onc Research

* Please note your request will be accomodated on a first come first served basis.

3/1/2021
Date________________________ Signature_________________________________________

2/23/2021