<p> 3rd and 4th Year Absence Request for Required and Elective Rotations</p><p> This form must be completed for ALL absences from clerkship and clinical elective activities.  Requests for religious observances are to be submitted at the beginning of the academic year. All additional requests for scheduled absences are to be submitted at least 8 weeks prior to the date(s) of absence.  Requests submitted less than 8 weeks prior to the date(s) may be rejected by the clerkship or clinical elective.  Two exceptions: 1. If notified of a residency interview late, this form must be submitted as soon as the student is notified of the interview and 2. Unforeseen absences because of an illness or family emergency in which case this form must be submitted no later than two days following the absence.  Students are required to maintain good communication with the clerkship director/clerkship coordinator about absences. Students will be required to submit documentation of absences (e.g. interview invitation email, conference program, etc). Scheduled absences are not and should not be considered approved until this form is signed by the clerkship director or coordinator. Failure to complete this form may be reflected in the student’s professionalism evaluation.</p><p>Time off request – to be completed by the student:</p><p>Student Name: ______Clerkship: ______Block #: ______List date(s)/time for absence:______Reason for absence (please be specific) ______</p><p>Student Signature: ______Date: ______</p><p>For completion by Clerkship Director or Clerkship Coordinator:</p><p>Date Request Received: ______</p><p>The absence(s) above have been categorized as (please check below): APPROVED OTHER  Jury Duty  Step 2 CK  Religious Observances  Personal medical illness  Residency Interviews  Missed Clerkship time because of travel complications  Conference (only if presenting)  Other ______ Unanticipated Family/Personal Emergency  Needed diagnostic, preventative, and therapeutic health services ** Step 2 CS is considered a working day and is not subject to this policy </p><p>Documentation for absence request received:  Yes  No The absence(s) above require remediation:  Yes  No</p><p>Plan for Remediation: ______</p><p>______</p><p>Final Tally of Days Missed (to be entered on the final grade form in E*Value): # Approved absences not remediated ______# Other absences remediated ______# Other absences not remediated______</p><p>Clerkship Director or Coordinator Signature: ______Date:______</p>