Clerkship and Post-Clerkship Absence Request Form

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.

Name*

Email*

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.

Class Year*

At the time of the absence request

Select

Department*

Select

Course Type*

Select

Course Name*

Course Start Date*

Course End Date*

Course Duration*

Select

Leave Date*

Please enter the first date of the requested absence

Return Date*

Please enter the requested return date from the absence

Does this fall on an exam day?*

Select

Reason*

Select

Request Details

Number of Days Requested*

Enter as a number only. May use 0.5 for half days. Any comments may use the comment section below

Comments

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

File Upload

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

Drag and drop files here or

Send me a copy of my responses