College of Optometry
OD1 to OD3 Anticipated Student Absence
Fill-in, Printout, Obtain Instructor Signatures
& Deliver to Dr. Reich for his signature.
First Name:
Last Name:
NSU Email:
Requests considered for Class / Labs only.
Request must be submitted 30 days before term begins.
Please note:
Honoring a late request will be the exception rather than the rule
and the reason for the request must be extremely compelling for the request to be granted.
Affected Term:
Summer
Fall
Winter
Spring
Dates, Courses and Instructors
Enter one request per line
Class of:
Requested Date(s)
Format: MM/DD/YY
Clinic
Class / Lab Name
Name of
Instructor of Record
Approved Signature
Not Approved Signature
1. 2. 3. 4. 5. 6.
1. 2. 3. 4. 5. 6.
1. 2. 3. 4. 5. 6.
1. 2. 3. 4. 5. 6.
Reason for Request:
If more space needed, print additional forms.
