Department of Neurology Resident Unexpected Absence Form
Contact Information
For questions, please contact Neurology.Residency@cuanschutz.edu
Please fill out the unexpected absence request form below.
Full Name: *
Email: *
Date of absence: (MM/DD/YYYY): *
Anticipated return date: (MM/DD/YYYY): *
Rotation: (At the time of requested leave) *
Location: * UCHVADHCHCOOther/Comments
Did you miss your continuity clinic? *
Yes No
Was Jeopardy Call needed? *
If so, who is covering:
Reason for absence: *
Unexpected Absence Requirements: *Please confirm that you did the following
Inpatient, Consult, EMU or Subspecialty Clinic Notified the administrative chief resident Notified the senior resident or attending on service
Electives or Continuity Clinic: Notified the administrative chief resident Notified the individual clinics Notified the supervising attending/fellow
Comments:
