Student Absence Request

Refer to the current approved Academic Calendar to confirm dates and impacted courses.

College of Medicine-Phoenix Attendance and Absence Policies to reference:

If requesting an absence from multiple blocks/courses/clerkships/electives, you must receive approval from EACH impacted block/course/clerkship/elective for your absence to be fully approved (unless a single approval is given from the Office of Student Affairs).

Student Info

First Name *

Last Name *

What MD class are you currently a part of? *

UA Email Address: *

Pre-Clerkship Absence Request

Standard - Most common request for absence, such as minor illness, personal family event, conference presentation, etc. Please describe the absence request in the box on this form, and your request will be forwarded to the block/course/clerkship director for consideration.

Religious Accommodation - Absence for the purpose of religious practice or belief, in accordance with the University of Arizona Religious Accommodation Policy. Your request will be forwarded only to the Associate Dean of Student Affairs.

Personal / Sensitive Nature - Absence due to a personal and/or especially sensitive issue you wish to discuss confidentially with the Associate Dean of Student Affairs. Your request will be forwarded only to the Associate Dean of Student Affairs. You should then make contact with the Associate Dean to discuss the issue. You do not need to describe the issue in detail on this form.

Type of Absence Request *

Standard

Personal / Sensitive Nature / Religious

COVID-19 Related

Do you wish to engage remotely if an option is available?

Yes

No

Select one

Positive test for COVID-19 (Isolation)

Close contact with someone with COVID-19 (Quarantine)

COVID-like illness

Refer to the CDC guideline below for Isolation. You should isolate for a minimum of 5 days from onset (dependent upon symptoms) and should continue consistent mask usage upon your return to campus or clinical activities. If you have not done so already, you will also need to upload documentation of your positive test result to Campus Health by clicking here. Call Campus Health (520-621-9202) or your medical provider if you have medical questions or are concerned about your health.

If You Test Positive for COVID-19 (Isolate)

Everyone, regardless of vaccination status.

· Stay home for 5 days.

· If you have no symptoms or your symptoms are resolving after 5 days, you can leave your house.

· Continue to wear a mask around others for 5 additional days.

If you have a fever, continue to stay home until your fever resolves.

First day of symptoms and/or first day of positive test result (whichever came first).
+

Close contact is defined by the CDC as being within 6 feet of a person with confirmed COVID-19 for a minimum of 15 consecutive or cumulative minutes over a 24 hour period. This does not include exposures in which the affected person is consistently wearing a mask, nor does it include clinical encounters in which proper PPE and precautions are utilized. If you have received your COVID-19 booster, you do not need to quarantine. Please include the date(s) of close contact. You do not need to provide personal details. Please refer to the CDC guideline below and consider testing on day 5. If you develop symptoms, get a test and stay home.

If You Were Exposed* to Someone with COVID-19 (Quarantine)

If you:

Have been boosted
OR
Completed the primary series of Pfizer or Moderna vaccine within the last 6 months
OR
Completed the primary series of J&J vaccine within the last 2 months

· Wear a mask around others for 10 days.

· Test on day 5, if possible.

If you develop symptoms get a test and stay home.

If you:

Completed the primary series of Pfizer or Moderna vaccine over 6 months ago and are not boosted
OR
Completed the primary series of J&J over 2 months ago and are not boosted
OR
Are unvaccinated

· Stay home for 5 days. After that continue to wear a mask around others for 5 additional days.

· If you can’t quarantine you must wear a mask for 10 days.

· Test on day 5 if possible.

If you develop symptoms get a test and stay home

If you develop symptoms, please get tested and stay home. You may return to campus or clinical activities upon receiving a negative test and improvement of symptoms. If you receive a positive test, please resubmit an absence request for the appropriate duration of isolation. You do not need to provide a description of symptoms or personal details below. If you have questions or are uncertain about whether you may return to campus/clinical activities, please call Campus Health at 520-621-9202.

Absence Request

Absence Request Type *

Standard - Most common requests for absence, such as minor illness, personal family event, conference presentation, etc. Can be used for any absence request that does not exceed the maximum number of absences per clinical block. Approval will be granted automatically as long as the request meets the criteria.

Personal - For absences that do not meet the standard absence request requirements. This option may be used if the cumulative number of absences exceeds the maximum allowable absences per clinical block and/or if the absence request does not meet the policy requirements. Personal requests will be reviewed and approved on a case-by-case basis by the Office of Student Affairs. Reason for absence (should fall within one of the following categories.

Provide an explanation below.
Note: You do not need to include sensitive medical information. This response will be viewable by the Student Affairs office. If you prefer not to share the reason for absence on this form, indicate this in the text box below and email the Associate Dean of Student Affairs directly within 24 hours. *

Check the box corresponding to each of the following statements indicating your attestation in accordance with the University of Arizona College of Medicine’s Honor Code.

My absence meets one of the following reasons.

Presentation at a professional conference or leadership activity
Religious observance
Personal circumstances
Personal wellness
Residency interviews and application-related activities

*

I agree

My cumulative absences for this curricular unit will not exceed an average of 0.5 days per week of rotation (i.e. I will not exceed 2 days of absence in a 4 week rotation) *

I agree

I will not miss ANY mandatory synchronous sessions during PPDA, including LPC activities. If any required PPD sessions will be missed, a personal absence request must be submitted to ensure an absence does not result in subsequent changes to your scheduled clerkship(s). *

I agree

My absence request meets timeliness requirements as outlined in the Years 3 and 4 Attendance and Absence policy for one of the following reasons:

I am submitting this absence request more than 30 days in advance of my absence.
I am submitting this absence request with less than 30 days notice as this was the earliest opportunity due to reasons outside of my control (i.e. acute illness, personal emergency, residency interview invite with short notice).

*

I agree

I understand that this absence request will be automatically approved in accordance with the Honor Code. Inaccurate representation on the form itself or during my communication with curricular faculty would represent a failure to meet professionalism and trustworthiness expectations as outlined in the Educational Program Objectives and would be considered a violation of the Honor Code policy. Dishonesty on this form may affect student assessment and result in an Honor Code violation. *

I agree

I have notified my course director, site director, and clinical team of my absence (attending or senior resident I am working with, as applicable), and I will work with them to complete an absence remediation plan. *

I agree

Absence Dates

First Day of Absence * +

Absence Start Time *

Last Day of Absence * 🛈 +

Absence End Time *

Exams

Will you be missing an exam? *

Yes

No

Date of Exam * +

Date you would like to reschedule exam * +

Impacted Curriculum

Pathway *

IMS - Introduction to Medical Studies	PMBLD - Principles of Molecular Basis of Life & Disease
PCVH - Principles of Cardiovascular – Hematology	LLE - Leadership, Learning and Ethics
CP - Clinical Practicum	MRSP - Master’s Report Scholarly Project
PCIM - Principles of Communication in Medicine	OS - Principles of Organ Systems

First Year *

Second Year *

CCE - Community Clinical Experience	CAP - Capstone
DOC - Doctoring 2	GIMDN - Gastrointestinal System, Metabolism, Diabetes and Nutrition
PC3 - Patient Centered Care Course	REBLS - Reproduction, Endocrine & Behavior Through the Lifespan
TRAN - Transitions

Doctoring Attestation: *

I understand that missing a Doctoring session requires scheduling a make-up, and it is my responsibility to reach out to the Doctoring director to confirm my attendance for that makeup session, otherwise, (as per the syllabus) a formative level one may be issued.

Select your assigned Doctoring day. *

Tuesday

Wednesday

Thursday

Select which session in Doctoring you will be absent for: *

GIMDN

REBLS

Final OSCE

Third Year *

PPDA: Clerkship *

PPDA: Modality *

Asynchronous

Synchronous

Simulation

Fourth Year *

Site Name: *

Block: *

Makeups taking place during Capstone's weeks must also be communicated to the Capstones team (by the student) within 48 hours of your Doctoring absence to avoid conflict. Doctoring makeup sessions typically run from 1-5pm and will cover all content and SP encounters missed.

Reason for Absence

Reason for absence:
Do NOT share confidential medical information on this form.
*

(Optional) You may upload supporting documents, if available:
Do NOT upload any medical records or protected health information.

CA - Clinical Anatomy	CAP - Capstone
CCE - Community Clinical Experience	CVH - Cardiovascular - Hematology
DOC - Doctoring I	ITM - Introduction to Medicine
MBLD - Molecular Basis of Life & Disease	MSNSI - Muscoloskeletal and Nervous System I
NSII - Nervous System II	PAL - Personalized Active Learning
PC3 - Patient Centered Care Course	PRAB - Pulmonary, Renal, Acid-Base

ITM	MBLD	Fall Mini OSCE
MSK	Neuro	Winter OSCE
CVH	Spring OSCE	PRAB
Final OSCE	GYN Skills

Ambulatory Elective	Elective
Family Medicine Clerkship	LIC - Longitudinal Integrated Clerkship
Medicine Clerkship	Neuro Clerkship
Obstetrics and Gynecology Clerkship	Pediatrics Clerkship
PPDA	Psychiatry Clerkship
LPC - Longitudinal Patient Care	Surgery Clerkship

Family	Medicine
Neuro	OB Gyn
Pediatric	Psychiatry
Surgery

Critical Care	Elective
Emergency Medicine Clerkship	PPDB
Sub-Internship