STANFORD HOSPITAL & CLINICS by ZM95ea0

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									                        STANFORD HOSPITAL & CLINICS
           PHYSICAL MEDICINE & REHABILITATION RESIDENCY PROGRAM
           RESIDENT/FELLOW REQUEST FOR VACATION/LEAVE OF ABSENCE

All interns/residents/fellows requesting a vacation/leave of absence for vacation, illness, including
maternity leave, educational or personal leave must complete this form. This form is not required for the
three weeks of paid time off per year of educational leave routinely granted by some programs.

Resident Name:



Service:



Requested Dates:               Start Date:            Stop Date:                 Total Work Days:


Reason:
(Vacation/Leave, etc.)
If educational leave, attach a copy of registration form and agenda.


Specific Service           Date(s):                   Name of Covering           Service Attending-
(Ward/Clinic):                                        Resident: Signature        Approval Signature:




Remember to include clinic coverage even if you are on a ward rotation.


Requesting Resident Signature:

Signature of Chief Resident:

Signature of Jeffrey Teraoka MD, Program Director

Signature of Teresa Goodman (SCVMC Only):

								
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