Vacation/CME/Time Off Request Form 2025-2026

Vacation/CME/Time Off Request Form
REMINDERS:

Vacation must be requested at least 60 days in advance.

Prior to submitting, please ensure:

1) You have adequate vacation/CME days remaining to make the request (20 total vacation, 3 CME days, 2 personal days and "24 hours" sick time)

2) Vacation does not violate the 25% rule (you may miss no more than 25% of a single block)

3) Vacation does not fall on the week AFTER an away rotation

4) All associated weekends and short calls have been traded/covered.
Your Name*
Your Email Address:*
example@example.com
Type of Days off being requested:*

VacationCMEOther
Time off Start Date*

MonthDayYear
Date
Time off End Date*

MonthDayYear
Date
Total Number of Vacation Days Requested
Number of days in advance request submitted
Your request is less than 60 days in advance. Please provide additional information:*
Attestation*

I attest that I have adequate vacation or CME days remaining to make this requestI attest that I have requested short call trades during this date range (if applicable)I attest that my vacation will not violate the 25% rule outlined at the topI attest that my vacation does not fall on the first week after an away rotationI attest that I will remind my attendings of this vacation, if approved, at the start of the block AND one week prior to the start of my vacation
Where are you scheduled to work during this time?
Sites:*

InpatientCL/EDExeter ClinicLindsay ClinicPHP/IOPCountyGood SamInpatient MedicineED MedicineNeurologyTYSBTCOEFresno PHFCRTOther
If on CL block, I have ensured that no one else is on vacation at the same time

YesNo, I'll be right back...
What attending(s) will you be working with during this time?

(If you do not know, please ask the Chiefs prior to submission!)
Attending 1*
Attending 2
Attending 3
Attending 4
Attending 1 Email
example@example.com
Attending 2 Email
example@example.com
Attending 3 Email
example@example.com
Attending 4 Email
example@example.com
Other Attending Name:

First NameLast Name
Other Attending Email Address:
example@example.com
Comments
Signature*

Clear
Date submitted:*

MonthDayYear
Date
Should be Empty:

Vacation/CME/Time Off Request Form

Where are you scheduled to work during this time?

What attending(s) will you be working with during this time?