Student Sick/Unplanned Leave Form IMPORTANT: 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. Name(Required) First Last UFID(Required) Class(Required)1DN2DN3DN4DNReason for absence(Required) Short description (i.e. positive COVID test, doctor's note for illness, etc).Absence Begin Date(Required) Month Day Year Absence End Date(Required) Month Day Year Will you miss and need to reschedule an exam?(Required) Yes No Course Exam Description(Required) Will you miss clinic?(Required) Yes No Patient Coordinator(Required)Starla BrinsonBeth BunnellJoanna ClaxtonPauline ColemanKimberly GoldenJanet GouldTimothy GranthamTara MillerWill you miss a clinic rotation?(Required) Yes No Rotation Description(Required) Please describe the course or clinical location you will miss during your absence.(Required) (e.g. SOS, Teams Clinic, Course Lecture, Radiology, etc.)Please describe the course or clinical location you will miss during your absence. (e.g. SOS, Teams Clinic, Course Lecture, Radiology, etc.)Please describe the course or clinical location you will miss during your absence. (e.g. SOS, Teams Clinic, Course Lecture, Radiology, etc.)Please describe the course or clinical location you will miss during your absence. (e.g. SOS, Teams Clinic, Course Lecture, Radiology, etc.)Please describe the course or clinical location you will miss during your absence. (e.g. SOS, Teams Clinic, Course Lecture, Radiology, etc.)
