Clerkship and Post-Clerkship Absence Request Form

This form must be used for all absences related to the clinical learning environment, including PCAT clerkships as described below:

PCAT 1 and 2: Family Medicine, Pediatrics and Surgery clerkships

PCAT 3: Emergency Medicine, Internal Medicine, Ob-Gyn, and Psych-Neuro Clerkships

PCAT 4: AI, IPM IV, and Selectives


Please see policy for details.

 
 

Please use your official school email address. Requests that do not use this email format will not be approved and will need to be re-submitted.

 

At the time of the absence request

 
 
 
 
 
 
 

Please enter the first date of the requested absence

 
mm/dd/yyyy
 

Please enter the requested return date from the absence

 
mm/dd/yyyy
 
 
 

If this is a partial day request, please specify times.

 

You may be requested to provide evidence to document the reason for time off.

Drop your files here