Personal Time Off Request Form 2023-2024

Personal Time Off Request Form 2023-2024
Resident Name*

First NameLast Name
Email*
example@example.com
Request Date*

MonthDayYear
Date
Up to 13 hours of personal time is allowed before requiring pre-approval by the Program.

Personal Time must be requested at least 7 days in advance unless it is an urgent/emergent matter.

Personal appointments should be booked in a manner that least impacts patient care, ie at the end or beginning of the day, etc.

Start time should be from when you are requesting to LEAVE your rotation site, not when your appointment starts.

If the time off needed exceeds 4 hours, it will be counted as a 1/2 sick day instead.
Start Date and Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
End Date and Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
What rotation site are you on during this time*

Inpatient PsychCL/EDOutpatientPHP/IOPForensicsAddictionsGeriatricsChild OutpatientSTAR ChildMedicineNeurologyED MedicineCRTOther
Urgent/Emergent request submitted within 7 days?*

YesNo
Details (optional)
*Please include which clinic you are at (i.e. Lindsay, Exeter, VAIC) and if you have PHP/IOP or therapy supervision during this time.
Signature*

Clear
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