OD-4 Student Leave Request

Month
Calendars
Year 		Student Name:
First:
Last: 		Email Address:
Approval information will be sent
to E-mail address specified above. 		Calculator
Requests considered for Fourth Year OD rotations only.
Request must be submitted two months 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.

Effected Term: Summer Fall Winter Spring
Rotation: 1 2
Class of:

Exact Date(s) Requested:
[MM/DD/YYYY]
Affected Clinics
Broward Primary Care / Low Vision - Geriatrics
          Drs. Black & Patterson
NMB Primary Care / Low Vision - Geriatrics
          Drs. Frauens & Patterson
Peds / Binocular Vision
          Dr. Tea
Cornea / Contact Lens
          Dr. A. Janoff
Reason for Leave Request:
                     
Reports (updated daily)
Students assigned to Peds/Binocular Vision and Cornea/Contact Lens during the FALL term should contact the Chief of Service to arrange for make-up of anticipated leave during the SUMMER term. Students assigned to Peds/Binocular Vision and Cornea/Contact Lens during the WINTER term should contact the Chief of Service to arrange for make-up of anticipated leave during the SPRING term.