Vacation Request Form
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1
2VACATION REQUEST FORM
All schedule and vacation changes must be made through the Housestaff Office.
Sign up for three weeks of vacation and one week of educational leave. You may only take one week of vacation off any
subspecialty rotation. These weeks will be protected from jeopardy call. Please be sure to work with the contact person for each
elective (listed below) to request the dates you wish to take vacation or educational leave. The contact person in the subspecialty must
sign and date this form. The appropriate person for your Weekly Continuity Clinic must also sign this form.
Vacation changes must be requested and approved no later than 60 days prior to the start of the affected rotation.
Please return all of your completed vacation request forms to Kristy Zanao in the Housestaff Office Room 8608 in the
Academic Office One Building or fax to 303-724-1799. The deadline for receipt of the completed form is May 28, 2010.
The Jeopardy Schedule can and will accommodate your vacations. Moreover, you can designate on the bottom of this form any other
special dates that you do not wish to be on call for jeopardy. Please indicate any months that you will be doing “away” rotations so
that you are not placed on jeopardy during those months.
VACATION REQUESTS FOR 2010-2011
NAME: _______________________________
PAGER #: ________________
(please print)
Elective
Dates
Elective Signature/Date
Continuity Clinic Signature
1. ______________________
_____________
_________________________
_______________________
2. ______________________
_____________
_________________________
_______________________
3. ______________________
_____________
_________________________
_______________________
Educational Leave
Dates
Signature/Date
Continuity Clinic Signature
4. ______________________
_____________
_________________________
_______________________
AWAY ROTATIONS
Month
Location
1.
__________________________
_____________________________
2.
__________________________
_____________________________
Dates to protect from Jeopardy and other requests:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
(OVER)
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