Child Interview Time off Request Form

Child Interview Time off Request Form
Name*

First NameLast Name
Your email:*
example@example.com
Fellowship Program Name and Location*
Date of Interview*

MonthDayYear
Date
Type of Interview:*

In PersonTele/Remote
Dates Requested Off:

For partial day interviews, please discuss with your attendings how much time to request off.
1st Day off requested:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Return to Work:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Number of Days off Requested*
What clinics are you scheduled at during that time?*

LindsayExeterCountyPHP/IOP/BHIPsychotherapy SupervisionED/CLPsych InpatientOther
Lindsay Email 1
example@example.com
Lindsay Email 2
example@example.com
Exeter Email 1
example@example.com
Exeter Email 2
example@example.com
County Email 1
example@example.com
County Email 2
example@example.com
Private Email 1
example@example.com
Private Email 2
example@example.com
Which attendings are you working with at that time?

Check "precisionpsych.com/kaweah" password: "kdhcd" to see who the scheduled attending(s) are at that time. If, there is no attending scheduled, enter Hwang and Perez into the boxes below.
Attending 1*
Attending 2
Attending 3
Attending 4
Email of attending 1
example@example.com
Email of attending 2
example@example.com
Email of attending 3
example@example.com
Email of attending 4
example@example.com
Other Attending Name

First NameLast Name
Other Attending Email
example@example.com
Please be aware that you are limited to 8 days of time off for interviews. Any interviews beyond this will require the use of vacation/CME time. Does this request fall within the 8 day limit?*

YesNo, this is beyond the 8 day limit and I will be using Vacation/CME days
Upload Invitation Letter*

Cancelof
Resident Signature*

Clear
Todays Date*

MonthDayYear
Date
Should be Empty:

Child Interview Time off Request Form

Dates Requested Off:

Which attendings are you working with at that time?