Cardiology Division, A205
Clinical Center,
Cardiology Sub-Specialty Resident Absence
Form
This form must be completed
30 days prior to planned absences in order to
accommodate schedule changes. Failure to
complete this form can result in an unexcused absence from the Sub-Specialty
Residency Program, loss of salary for the dates involved, possible lack of
training credit for the missed period, and potential disciplinary action. Policy must be followed in regard to requests
for time off. This form must be
completed before it is turned in to the Program Coordinator or the Program
Support Staff. Additionally, there will be no time off granted to fellows who
are on a current clinical rotation. The
fellow is responsible for ensuring coverage in their absence. Failure to do so may result in disciplinary
action.
Sub-Specialty Resident Name:
Expected dates of Absence:
Rotation Name:
*No time off will be approved during a
clinical rotation.
Coverage:
Are you scheduled to be in
continuity clinic during this time? List dates
*If the answer is yes, you must notify the
faculty member you are assigned to in the continuity clinic and he/she must
initial your time off slip.
Continuity Clinic Faculty Member ____________________
Initials
Reason for Absence:
Type of Leave Requested:
Additional
Notes:
_________________________________________ _______________________
Signature: Attending Date
_________________________________________ _______________________
Signature: George S. Abela, MD Date
_________________________________________ ________________________
Signature: Linda East and/or Mary Metler Date