Flex Day Request | Department of Medicine

Flex Day Request

*NOTE* This form is intended for Internal Medicine Residents only □ Max Changes: You are allowed 2 flex days per year □ 75% Rule: Must complete a minimum of 75% of each rotation □ Vacation: No vacation taken during this block □ Call Coverage: You have found coverage if you are past the deadline

Resident Name*
First Last
Resident Email*
Name of Service Contact
Can be CMR, or Service Contact - see contact list
First Last
Service Contact Email
Program Year*
- PGY1
- PGY2
- PGY3
- PGY4
Block Number
Number of Flex days requested*
- one
- two
Flex Day Requested*
MM slash DD slash YYYY
Second Flex Day Requested
MM slash DD slash YYYY