Internal Medicine Vacation Request Form

Use this form to add/remove vacation time from your rotation

Guidelines
1) Cancelling Vacation - At least ONE block in advance
2) New Vacation - At least TWO blocks in advance
3) No Vacation on the following: CTU blocks or block 7 (no matter what the service)
4) 75% Rule - No additional leave booked (flex days, conference, etc.
Program Year
- PGY1
- PGY2
- PGY3
- PGY4
Resident Name*
First Last
Resident Email*
Rotation Information
I would like to:*
- Select All
- Add Vacation Time
- Remove Vacation Time
BLOCK #*
Rotation Name/Site*
New Vacation Dates Requested (FROM)
MM slash DD slash YYYY
New Vacation Dates Requested (TO)
MM slash DD slash YYYY
Service Contact Name
First Last
Service Contact Email
Remove Existing Vacation Dates (FROM)
MM slash DD slash YYYY
Remove Exisiting Vacation Dates (TO)
MM slash DD slash YYYY
Service Contact Name - Removing Vacation
First Last
Service Contact Email - Removing Vacation
Reason for Request/Change

Rotation Information