Core 2 Clerkships Absence Request Form - UPENN Perelman School of Medicine

Please review the Perelman School of Medicine clerkship attendance/absence policy before submitting.

Clerkship Attendance/Absence Policy:
https://www.med.upenn.edu/student/secure/clerkships-core-2.html

Are you a Perelman School of Medicine student?
Today's Date Today's Date / MM / DD YYYY
Name Name First Last
Email
Which clerkship are you requesting time off for?
Is this a request for a religious observation?

Is this a request for a religious observation? Yes No
What type of time are you requesting?

What type of time are you requesting? Personal Day Non-Personal Day(s)
PERSONAL DAY
Date of Absence Date of Absence / MM / DD YYYY

If you have used your four allotted days, please contact Anna Delaney to discuss the need for additional time.
Year to date, how many personal days have you had approved?

If you have used your four allotted days, please contact Anna Delaney to discuss the need for additional time.
Any comments or notes to mention:
NON-PERSONAL DAYS
Dates of Absence

From: Dates of Absence

From: / MM / DD YYYY
To: To: / MM / DD YYYY
Non-Personal Days (please check the box that applies)

Non-Personal Days (please check the box that applies) Acute illness (if more than one day, you much provide a primary care provider note to Anna Delaney) Presentation of Scholarly Work (must email presentation details/confirmation to Anna Delaney) Other
If "Other", please explain:
How many non-personal days are you requesting?
Year to date, how many non-personal days have you had approved?
Any comments or notes to mention:
**PLEASE NOTE: If you are submitting this request with less than two weeks before the clerkship, you must send Anna Delaney an email, alerting her to the discrepancy in the timeline of the request.**
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Core 2 Clerkships Absence Request Form - UPENN Perelman School of Medicine

Core 2 Clerkships Absence Request Form - UPENN Perelman School of Medicine

PERSONAL DAY

NON-PERSONAL DAYS

**PLEASE NOTE: If you are submitting this request with less than two weeks before the clerkship, you must send Anna Delaney an email, alerting her to the discrepancy in the timeline of the request.**

PLEASE NOTE: If you are submitting this request with less than two weeks before the clerkship, you must send Anna Delaney an email, alerting her to the discrepancy in the timeline of the request.