Date Requested:____________
 
Presbyterian Hospital of Dallas
 
 
Internal Medicine Residency Training Program
 
 
Request for Vacation
 
 

 
 

___________________________________________________   (print)   requests permission for vacation

from ______________________ (Month, Day, Year)  through  ______________________(Month, Day, Year).

  I will return to work on _____________________________. (Month, Day, Year)
 

Rotation during this period: __________________________. 

 
I have verified that this vacation is not being taken with any other resident on this rotation
_______________________________________________
Signature
 

Associate Program Director

Approved:

 

___________________________________________

 

Housestaff Coordinator

Approved:

 

___________________________________________

 

Subspecialty Attending

Approved:

___________________________________________

   
  Vacation Balance: __________ days
  Days Requested:__________ days           Days remaining: ________
  Charts are Current and Up To Date: Yes ________       No ___________

CC:

CC:

Internal Medicine Clinic X 5052

Page Operator X 2564

Date Sent:_______________________

Date Sent:_______________________