Clinical Attendance Request Form

By filling out and submitting this form, you acknowledge that you have read and understand the attendance policy, and that the information you are submitting is true and accurate. For planned absences, please submit your request at least 4 weeks prior to date that you are requesting off. Reminder: You have a total of 6 personal days for the year.

Absence Form

Student Name

First and Last Name

Student Email Address

Student Name.#

Rotation Information

Type of Absence

Makeup Date Done

Reason of Absence

Please provide additional details (for partial days, indicate timeframe gone from rotation) describing your situation, if helpful.

Missed Rotation

Hours Missed from Rotation

(e.g. 4.5)

Number of Students on Rotation

Look up in One 45

Date of Absence

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