Southern Illinois University School of Medicine

Southern Illinois University School of Medicine - Community Service

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Community Service Project Follow Up Form

Congratulations on completing your project!

We need your help. It is important for us to measure and keep track of the impact of community service projects like yours. We ask that fill out this form as completely as possible. Most fields are required.

 

A summary of this form will be emailed to you upon successful completion.

 

Project Details



(Maximum characters: 50)
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First Name Last Name Email


Participant Details
Number Participating   Total Cumulative Hours
Faculty  
Staff  
Medical Students  
Residents / Fellows  
Graduate Students  
Physican Assistant Students  

(Enter the number of participants next to each type. Cumulative hours is the total number of hours the group participated. So, if two medical students each gave 3 hours the cumulative total would be 6 hours.)

Funding
$


YesNo
(If "YES", please provide funding source deatils below)




$

Impact

(e.g. school-children, families, homelss etc...)





(Maximum characters: 500)
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Send summary to: @siumed.edu
(Please enter only the first part of your siumed.edu address)

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"The mission of the Office of Community Health and Service is to provide leadership and coordination in engaging our communities to improve health and well being through citizenship, service, education, research and advocacy."

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