M3 Student: Request for Time Off

Name: ______Dan Kazmierski__________________

Region:_____North______Date:____9/14/15_______

Please indicate below, the date(s) requested off, the Discipline that will be missed (IM, FM, Peds, Surg, OB/GYN,
Psych, CED or ER), and if the time involves a burst. Also indicate if the time will be taken as personal time or
whether a makeup session is planned. Please note the following attendance policy when making requests:

Except in emergencies, all absences must be requested in advance.

Students are allowed 7 personal days during the M3 year. Days used for sicknesses or emergencies are
personal days.
Requests for excused absences that exceed these numbers must be accompanied by a written plan to
remediate the missed time. This plan must be co-signed by the Course Director or Supervising physician.
Students must use a full day of personal time if they are requesting any time off on a day when they
have white space. Students may use a day of personal time only if they are attending a clerkship during
the remaining day.
Students are only allowed to miss two CED Sessions all others require a remediation assignment.
Make-up time must be documented use the form for M3 Student: Verification of Makeup of
Excused Absences
if Block
Date:__9/18/15___ Discipline: am:______IM block___
Personal Day or
pm:______CED______
Make-up Required
Date:__________

Discipline: am:______________
pm:______________

Personal Day or
Make-up Required

Date:__________

Discipline: am:______________
pm:______________

Personal Day or
Make-up Required

Date:__________

Discipline: am:______________
pm:______________

Personal Day or
Make-up Required

Date:__________

Discipline: am:______________
pm:______________

Personal Day or
Make-up Required

Approved by: _______________________________________

Regional Assistant Dean

________________
Date

EDUCATION SPECIALIST TO COMPLETE:

Number of Personal Days Used to Date (including this request):___________________________________