INTERVIEW TIME OFF REQUEST FORM

Student may miss a maximum of two (2) days from a 4-week rotation with the prior approval of the course director.  Student may be required to make up missed days.  Course director may deny request.  No missed days from a 2-week rotation.

 

Instructions:

  1. Student must provide documentation of interview invitation/confirmation to course director
  2. Student must provide completed Interview Time Off Request Form to course director for approval
  3. Student must submit documentation of interview and APPROVED completed Interview Time Off Request Form to:

Division of Clinical Education

Room 119

2900 Queen Lane

Philadelphia, PA     19129

Fax:  215-843-7738

 

All documentation must be submitted to the Division of Clinical Education PRIOR to departing for interview.

 

 

Date:

E-Mail:

 

Name:

 

Phone:

Signature:

 

Pager:

 

Please indicate the ONE OR TWO SPECIFIC DATES you are requesting to be off.

Please show the dates in the grid according to where they will fall during your 4-week block.

Course Number/Name:

 

Course Director (name print):

 

Course Director (signature):

 

 

M

Tu

W

Th

F

Sa

Su

Week 1 of 4

 

 

 

 

 

 

 

 

Week 2 of 4

 

 

 

 

 

 

 

 

Week 3 of 4

 

 

 

 

 

 

 

 

Week 4 of 4

 

 

 

 

 

 

 

 

2/13/06

 

Form should be returned with supporting documentation to Division of Clinical Education, Room 119, Queen Lane.
Fax:  215-843-7738 // Tele:  215-991-8360