Resident Planned Sick Leave Request "*" indicates required fields Name* First Last Date* Month Day Year Number of days I am requesting:*Rotation ResponsibilitiesName of person who has agreed to cover my assignment rotation*My supervisor has this information.Call Schedule Responsibilities* I am NOT on call I am on call This person will be on call in my place and I have notified the Chief ResidentOutpatient Responsibilities (PGY-2,3,4) I have notified the clinic secretary I have informed my patients as appropriate This person has agreed to cover my outpatient needs (psychotherapy patient calls, clinic patient calls, etc.)Signature
