Student Absence Request

Refer to the current approved Academic Calendar to confirm dates and impacted courses.
 
College of Medicine-Phoenix Policies to reference:
Attendance Expectations and Absence Reporting Requirements Policy
Attendance and Absence - Years 3 and 4 Policy.
 
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 Associate Dean of Student Affairs).
 

Student Info

What MD class are you currently a part of? *

Type of 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 *
Do you wish to engage remotely if an option is available?
Select one
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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 Dates

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Impacted Blocks / Courses

Pathway Blocks *
First Year Blocks *
Second Year Blocks *
Longitudinal Courses
Third Year Clerkships & Electives *

Fourth Year Clerkships & Courses

Other than in cases of emergency, you must make your request at least 30 days before your requested absence.

 *
I acknowledge that once my absence is approved, I must seek additional approval from my site director. *

Reason for Absence


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