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___________________________________________________ (print) requests permission for vacation from ______________________ (Month, Day, Year) through ______________________(Month, Day, Year). |
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| I will return to work on _____________________________. (Month, Day, Year) | ||||||||||||||||||
Rotation during this period: __________________________. |
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I
have verified that this vacation is not being taken with any other resident
on this rotation
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_______________________________________________ Signature |
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Associate Program Director Approved: |
___________________________________________ |
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Housestaff Coordinator Approved: |
___________________________________________ |
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Subspecialty Attending Approved: |
___________________________________________ |
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| 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:_______________________ |
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