Attachment 1 Absence Notification Form – SAMPLE

Absence Notification Form - Third Year Medicine

Enter the following information: Your LAST name ______Your FIRST name ______Your NEOMED email address ______Student ID (minus the @ and initial zeros) ______Before you submit an absence notification form you must already have made arrangements with your course/clerkship site director on your make-up plan.

Have you contacted your course/clerkship site director and arrived at a plan for making up time and any required activities missed during absence? Yes No

Please note that you will be asked to state on this form the remediation plan that you worked out with your course/clerkship site director. Please do that before you complete this form.

What course or activity is affected by this absence? NBME subject exam Applications of Clinical Medicine Prerequisite to the Clinical Curriculum Human Values in Medicine 5 Family Medicine Clerkship Internal Medicine Clerkship OB/GYN Clerkship Pediatrics Clerkship Psychiatry Clerkship Surgery Clerkship Emergency Medicine Clerkship

If the absence results in you missing a required activity in more than one course, you must submit a separate absence report for each course.

This Question is Conditionally Shown if: (3 = Family Medicine Clerkship) At what clinical site is your Family Medicine clerkship? Aultman Hospital Cleveland Clinic Akron General Mercy Health St. Elizabeth Boardman Hospital Mercy Health St. Elizabeth Youngstown Hospital Mercy Health St. Vincent Medical Center (Toledo) MetroHealth System Mount Carmel Health System (St. Ann's) Riverside Methodist Hospital Summa Health System - Akron Summa Health System - Barberton Other (please specify) ______

This Question is Conditionally Shown if: (3 = Internal Medicine Clerkship) At what clinical site is your Internal Medicine clerkship? Aultman Hospital/Mercy Medical Center Cleveland Clinic Akron General Mercy Health St. Elizabeth Youngstown Hospital Mercy Health St. Vincent Medical Center (Toledo) MetroHealth System Mount Carmel Health System (West) Northside Regional Medical Center Riverside Methodist Hospital St. Vincent Charity Medical Center (Cleveland) Summa Health System - Akron Western Reserve Hospital Other (please specify) ______

This Question is Conditionally Shown if: (3 = OB/GYN Clerkship) At what clinical site is your OB/GYN clerkship? Aultman Hospital Cleveland Clinic Akron General Mercy Health St. Elizabeth Youngstown Hospital Mercy Health St. Vincent Medical Center (Toledo) MetroHealth System Mount Carmel Health System (St. Ann's) Riverside Methodist Hospital University Hospitals Southwest General Summa Health System - Akron University Hospitals Elyria Medical Center Other (please specify) ______

This Question is Conditionally Shown if: (3 = Pediatrics Clerkship) At what clinical site is your Pediatrics clerkship? Akron Children’s Hospital Mercy Health St. Vincent Medical Center (Toledo) MetroHealth System Other (please specify) ______

This Question is Conditionally Shown if: (3 = Psychiatry Clerkship) At what clinical site is your Psychiatry clerkship? Cleveland Clinic Akron General Heartland Behavioral Health MetroHealth System Northcoast Behavioral Healthcare Summa - ACH and St. Thomas Other (please specify) ______

This Question is Conditionally Shown if: (3 = Surgery Clerkship) At what clinical site is your Surgery clerkship? Aultman Hospital Cleveland Clinic Akron General Louis Stokes Cleveland VA Medical Center Mercy Health St. Elizabeth Youngstown Hospital Mercy Health St. Vincent Medical Center (Toledo) Mercy Medical Center (Canton) MetroHealth System Mount Carmel Health System (West or East) Northside Regional Medical Center Riverside Methodist Hospital Summa Health System - Akron Western Reserve Hospital Other (please specify) ______

This Question is Conditionally Shown if: (3 = Emergency Medicine Clerkship) At what clinical site is your Emergency Medicine clerkship? Aultman Hospital Cleveland Clinic Akron General Mercy Health St. Elizabeth Youngstown Hospital Mercy Health St. Vincent Medical Center (Toledo) Northside Regional Medical Center Salem Regional Medical Center St. Vincent Charity Medical Center (Cleveland) Summa Health System - Akron Union Hospital University Hospitals Portage Medical Center Western Reserve Hospital Other (please specify) ______

This Text Block is Conditionally Shown if: (3 = NBME subject exam) You selected the NBME exam. Even though it is technically a component of a clerkship, you should discuss this absence with Dr. Sperling ([email protected], 330.325.6778) and let the test administrator know as well as (Lisa Morris: [email protected], 330.325.6334). You do not need to fill out a separate absence notification for the clerkship.

Indicate the first and last day of the absence. If it is a one-day absence, the dates will be the same. If it is a fraction of a day, include that information in the comment field. First Date ______Last Date ______

Reason for absence: Illness Death in family Job/residency interview Presentation at Academic Conference Conference Presentation Other

This Text Block is Conditionally Shown if: (22 = Illness) In case of illness: A doctor's excuse may be required to be submitted to Academic Services. Consult the student handbook.

This Question is Conditionally Shown if: (22 = Other) You selected Other. Please explain: ______Further reason for absence if explanation is required: ______

Describe the plan for making up time and any required activities missed during absence as prescribed by course/clerkship site director: ______