Schedule, Elective and Clinic Change Requests

Elizabeth Presutto
Name: ___________________________________________ 8/9/19
Date: __________________

SCHEDULE OR CLINIC CHANGE REQUEST:

** Clinics must be cancelled 12 weeks in advance. **
I would like to switch my schedule in the following way:
_________________________________________________________________________________
I would like to change from pulmonology elective to QI project elective
_________________________________________________________________________________

_________________________________________________________________________________

X
Is this an elective switch? ______ Yes ______No Oct 15-28
Block Dates ________________________

1. If yes, you must notify the Elective Coordinators for the elective being dropped and added (see
list of coordinator contacts). If the contact is not listed, call Debbie Trust at 8-1142 or email
dtrust@som.umaryland.edu
2. Attach an email from the Elective Coordinator to confirm notification and turn into the Chief
Residents.

Interns: You must complete 1 FULL BLOCK ELECTIVE AT THE VA .

Pulmonology Consult
Elective being dropped: _____________________________________________________________
Quality Improvement Research
Elective being added: _______________________________________________________________

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Chief’s Approval:

_____________________________________ ______________________________________
Manoj Racherla, MD Cheryl Augenstein, MD
Change entered into amion on: ____________ Change entered into amion on: _____________

Clinic Changes: ______________________

_____________________________________
Barathi Sivasailam, MD
Change entered into amion on: ____________ Change entered/changed in amion on:_______
Debbie Trust

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You will receive a copy of this form back in your mailbox noting whether your requested change has been
approved or not.

6/7/2019