28th Annual Trainee Research Symposium

Medical Students, Residents, & Fellows—Wednesday, April 18, 2018

South Auditorium, Springfield Campus

NEW DATE: Graduate Students—Friday, April 26, 2018

WEST Auditorium, Springfield Campus

ABSTRACTS DUE THURSDAY, MARCH 1, 2018 BY 4 P.M.

GRADUATE STUDENTS ONLY – ABSTRACT DUE DATE EXTENDED: DUE MONDAY, MARCH 12, 2018; 4 P.M.

Application Form

Fill in the blue boxes with the information requested or mark an X.

Name:

First Name Last Name:

Title of Project (only one 1st author submission per trainee allowed):

Status:

Resident:	Medical Student:	Ph.D. Student:	Masters Student:

Department:

Email Address (Residents: list the email address you check most frequently. Graduate and medical students should use their siu or siumed email address only):

Phone Number:

Home or Cell Phone:	Lab Phone:

Name of Primary Mentor:

Primary Mentor’s Name:	Department:

Has primary mentor approved the version of the abstract that is being submitted?

Yes	No

Primary Mentor’s Phone Numbers:

Office Phone:	Lab Phone: