Fillable Printable Request for Time off Form
Fillable Printable Request for Time off Form
Request for Time off Form
REQUEST FOR TIME OFF FORM
Name: _____________________________________
Clerkship: ____________________________
Date Today: _________________________
Requested Dates for Time Off: _________________________________
Steps for Requesting Time Off
1. A student submits to the Clerkship Director the Request for Time Off form
at least 6 weeks prior to the start of that clerkship.
2. Clerkship Director will consult the Dean’s Office to see how many days off
the student has already had prior to this request.
3. Clerkship Director reviews the request and will approve with conditions or
deny.
4. Clerkship Director forwards the final decision and the Request for Time Off
form to the Dean’s Office where the attendance records will be maintained
for all clerkships.
Please Select One Category:
Immediate Emergency/Illness:
Student or immediate family illness or emergency. Student should contact the
clerkship director or designee immediately and request time off. Student should
submit the Request for Time Off form to the clerkship director within 24 hours.
Clerkship director can require this time to be made up if it exceeds two days.
Please indicate the dates you were off from the clerkship:
_________________________________________________________
Request to attend/or present at a professional conference:
This category also includes interviewing or taking the USMLE exams. These
events are known well in advance and the student should submit a Request for
Time Off form to the clerkship director at least 6 weeks prior to the start of the
clerkship to seek approval. Students are permitted to have a total of 2 days during
the third year and 2 days off during the 4
th
year to pursue these kinds of events.
Clerkship director can require this time to be made up if it exceeds two days.
Please indicate how this event will enhance your medical education. Please
indicate the name of the meeting, location and dates you request off. Please use
the back if necessary.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
School of Medicine
Office of the Dean
Mail code: L102
3181 S.W. Sam Jackson Park Rd.
Portland, OR 97239-3098
tel 503 494-8220
fax 503 494-3400
Office of Admissions
tel 503 494-8220
Continuing Medical Education
Mail code: L602
tel 503 494-8700
fax 503 494-0392
Development and Alumni
Relations
tel 503 494-0723
fax 503 418-1025
Education and Student Affairs
tel 503 494-8228
Graduate Medical Education
Mail code: L579
tel 503 494-8652
fax 503 494-8513
Graduate Studies
tel 503 494-6222
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Please indicate how your patient care duties will be covered while you are away.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Non Urgent Personal Reasons:
Request for Time Off for non urgent personal reasons such as weddings,
reunions, etc. are usually not approved by the clerkship director but can be
reviewed if you submit a Request for Time Off form. The clerkship director
requires all this time to be made up.
Please justify why this event is more important than participating in a required
clerkship.
_________________________________________________________________
_________________________________________________________________
Please indicate how your patient care duties will be covered while you are away.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Student Signature and Date:
_____________________________________________ Date: ______________
Clerkship Director Signature and Date:
_____________________________________________ Date: ______________
Action Taken:
Denied __________
Approved __________
Please state the conditions for the approval (make up days, etc)
Clerkship Directors - submit to Vicki Fields, L102
fields@ohsu,edu
fax 494-3400
