Student Sick/Unplanned Leave Form » College of Dentistry

PLEASE READ: This form is required for students who are missing school/clinic due to unexpected circumstances. If you are missing clinic, this form is to be filled out AFTER you have notified your patient coordinator of your absence. This form is not a replacement for notifying your patient coordinator. Unplanned absences DO count toward leave days for 3DN and 4DN students. Documentation is required (e.g. doctor’s note) to excuse the absence, per the student handbook.

Name(Required)

First Last

UFID(Required)

Class(Required)

Reason for absence(Required)

Short description (i.e. positive COVID test, doctor’s note for illness, etc).

Absence Begin Date(Required)

Absence End Date(Required)

Will you miss and need to reschedule an exam?(Required)

Yes

Course Exam Description(Required)

Will you miss clinic?(Required)

Yes

Patient Coordinator(Required)

Will you miss a clinic rotation?(Required)

Yes

Rotation Description(Required)

Please describe the course or clinical location you will miss during your absence.(Required)