ࡱ> mol#` 06Fbjbj5G5G \JW-W-$////\0$R,4022223I5-6tQQQQQQQ$Sh'VQ63366Q22MR7776"22Q76Q77NP2(0 C喛x/6:nP,bQDcR0RPPV6VXPVPx66766666QQ7666R6666 &$ &$ Flexible Vacation Leave Request Instructions Flexible vacation is available to 2nd and 3rd year Internal Medicine Residents Please review the flexible vacation rules in section C before filling out this form. Note that you may flex up to 7 vacation days and they must all come from the same 7 day period. You may not add flex vacation days to an existing one or two-week vacation period without special approval from the Program Director. Return the form to Bill Niemeyer via email, in person in the housestaff office, or fax (503-494-5636). Please call Bill (503-494-8357) or email with questions. You will hear back from us within 5 days of submitting your request. If you need it sooner, please call first. In general all requests should be submitted 6 weeks in advance to allow time for clinic and schedule adjustments. To complete this form, place your cursor over the fields following each question and type your response. Click on "yes" and "no" boxes". You may "tab" between fields. Save as a word document. A. Vacation Request Resident Name:  FORMTEXT       1. Vacation is requested for: Date(s):  FORMTEXT       Name of Rotation:  FORMTEXT       Total number of days:  FORMTEXT       2. Requested vacation will come from: Name of rotation:  FORMTEXT       Date(s):  FORMTEXT       3. I am scheduled for a continuity clinic during the requested vacation: Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, Clinic name:  FORMTEXT       Clinic date:  FORMTEXT       4. I am currently scheduled to be on Jeopardy during my requested vacation: Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, my substitute coverage is: Insert name of resident  FORMTEXT       5. I am currently scheduled for an ED shift or a Kaiser call shift: Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, my substitute coverage is: Insert name of resident  FORMTEXT       B. LEAVE THIS SECTION BLANK  For Medicine Education Office Use: 1. Clinic schedule verified:  FORMCHECKBOX  Initials:  FORMTEXT       Date:  FORMTEXT       2. Jeopardy schedule verified :  FORMCHECKBOX  Initials:  FORMTEXT       Date:  FORMTEXT       3. ED scheduled verified:  FORMCHECKBOX  N/A:  FORMCHECKBOX  Initials:  FORMTEXT       Date:  FORMTEXT       4. Kaiser Schedule verified:  FORMCHECKBOX  N/A:  FORMCHECKBOX  Initials:  FORMTEXT       Date:  FORMTEXT       5. Request approved: Yes:  FORMCHECKBOX  No:  FORMCHECKBOX  Approved by:  FORMTEXT       Date:  FORMTEXT       6. Ambulatory coordinator notified:  FORMCHECKBOX  Initials:  FORMTEXT       Date:  FORMTEXT       7. Rotation coordinator notified:  FORMCHECKBOX  Initials:  FORMTEXT       Date:  FORMTEXT       8. On Call schedule modified:  FORMCHECKBOX  Initials:  FORMTEXT       Date:  FORMTEXT       C. Flexible Vacation Rules Vacation requests shou !/RTZ\}~ 6 7 > A a  ! # $ 4 C M [ ^ _ r y  Ӿŀŀyŀŀŀŀŀ hq >*CJ h D>*CJhVhh5>*CJhN5>*CJhVh A5>*CJhVhx5CJhVhx5>*CJ hN>*CJ h'=$>*CJ hh>*CJ hx>*CJhL*hL*>*CJH* hL*>*CJ h'=$CJ h'=$CJ h'=$5>*/ !./~ $ _ C  4 6 | ~ `gdL* & F L^`LgdL* & F L^`LgdN & F L^`Lgdx6F @ B C   4 P T V j l n x z | ~ ѶŪť񟙓{ue{U{jhj%CJUmHnHujvhj%hj%CJU hj%CJjhj%CJU h$Y5CJ h'=$5CJ h$YCJ h'=$CJ hb CJ hL*>*jhj%>*CJUjhL*>*CJUjhL*>*CJU hL*>*CJhL*5>*CJh'=$5>*CJ h D>*CJ h'=$>*CJ hnE>*CJ! FJrx$vx&( ^`gdA7'^gdA7' ^`gdA7'gdb `^ $ & : < > H J L Nnrt봭۝ۇ끭qjHhj%hj%CJU h$YCJjhj%hj%CJU hb CJj`hj%hj%CJU h'=$5CJ h'=$>*CJjhj%CJUmHnHujhj%hj%CJU hj%CJjhj%CJU h'=$CJ h$Y5CJh$Yh'=$,vx "0FNPdfhrtz|覆}m}g h9CJjhj%hj%CJUjhj%CJUmHnHujhj%hj%CJU hj%CJ hb 5CJj0h'=$CJUjh'=$CJUjh'=$5CJUjh'=$5CJU h'=$5CJ hA7'CJ hb CJ h'=$CJjhj%CJU' ">@BDJLhjlp &(*,.}pjh'=$CJU hb CJjhj%CJUmHnHujthj%hj%CJU hj%CJjhj%CJU hA7'CJjh'=$5CJUjh'=$5CJUjh'=$CJUjh'=$CJU h'=$CJ h'=$5CJ hA7'5CJ*(P<>` ^` ^`gdA7' 8^8` LV"068~ȸΨ΢آ}p}`Ψ΢jhj%hj%CJUjHh'=$CJUjh'=$CJUh'=$h'=$5CJ hq 5CJh'=$h95CJ h'=$CJjhj%CJUmHnHujhj%hj%CJU hj%CJjhj%CJU hA7'CJ hA7'5CJjh'=$5CJUj^h'=$5CJU%Z\xz|,.JLNZ\xz|Ͽϲ嬜嬌ϿϿrjj h'=$CJUj h'=$CJUj hj%hj%CJUj hj%hj%CJU hj%CJjh'=$CJUjh'=$CJU h9CJ h'=$CJjhj%CJUmHnHujhj%CJUj4hj%hj%CJU(02NPR^`|~$ɹϳϩϜϩϏoϳj hj%hj%CJUj hj%hj%CJUj* h'=$CJUj h'=$CJUjh'=$CJU h9CJjJ hj%hj%CJU hj%CJ h'=$CJjhj%CJUmHnHujhj%CJUj hj%hj%CJU($*.0LNPTX\^z|~NPlnpľĞľĞ{ľkĞjhj%hj%CJUjLh'=$CJU h9CJjhj%hj%CJUjhj%CJUmHnHuj`hj%hj%CJU hj%CJjhj%CJUj h'=$CJUjt h'=$CJUjh'=$CJU h'=$CJ h'=$5CJ*&(DFH^`tvx02FHJTVdfɹɬɹojVhj%hj%CJUjh'=$CJUjvhj%hj%CJUj hj%hj%CJUjh'=$CJUjh'=$CJU h9CJ h'=$CJjhj%CJUmHnHuj,hj%hj%CJU hj%CJjhj%CJU+fz|~:::d<<<V=z??,@@@DEEF"F*F,F4F6Fʲʔʎʈʂ| hACJ h;CJ h8CJ hnECJhnEhnECJaJh9h'=$5CJhnE5CJhh9h'=$5CJhU h9CJh'=$ h'=$CJjhj%CJUmHnHujhj%CJUjhj%hj%CJU hj%CJld be entered 6 weeks prior to planned leave. Any exceptions will be considered on a case-by-case basis. Residents can use 7 days of flexible vacation per academic year taking such days from one week of the three weeks allowed. Residents may not take flexible days from more than one 7 day vacation period without special approval from the Program Director. Unused days cannot be transferred to the following academic year. Flexible vacation can be taken in allotments ranging from one day to seven days in a row. Flexible vacations cannot be taken out of ICU, ward or night float rotations. Vacations from Emergency Room rotations will present special challenges but are not absolutely excluded. Except during Ambulatory, Elective, and Kaiser rotations, residents on the same rotation should not take vacations simultaneously. Requests will be approved on a first come, first serve basis. No more than two continuity clinics can be cancelled per year as a result of flexible vacation. Any additional cancellations will have to be made up. It is the resident s responsibility to arrange jeopardy, ED or Kaiser call coverage for shifts that fall on any requested flexible vacation days. Final approval is contingent on specific plans for any required coverage. The Housestaff Office will notify the affected rotation faculty and clinics of your planned absence. It is helpful for you to double check that they are aware of your upcoming flex vacation date(s) at the start of the rotation that the vacation is scheduled during. 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