Absence Request Form
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1If you anticipate or need to plan for an excused absence, e.g., required medical appointment, a written request should be submitted to the
Department Head in advance for consideration/approval by the faculty. Approval of requests for excused absences will require the inclusion of the
plan from the student for making up missed content. Request for excused absences for activities other than health issues, family emergencies, etc.,
will be scrutinized closely by the faculty and will be judged individually and on their own merits relative to the value of the content to be missed
and probability of recreation of missed content… it should be submitted to the Department Head at least three weeks in advance… You should not
assume approval of a request for excused absence until you receive notification of faculty approval. (Excerpts from UNG Physical Therapy Student
Handbook)
SPT Name:
thru
Dates of Requested Absence: _____________
______________
Check ALL classes that will be missed if absence is approved:
DPT I
DPT II
☐ 7111 Gross Anatomy and Embryology
☐ 7332 Patient Care Skills III: Interventions
☐ 7121 Medical Terminology (online)
☐ 7512 Clinical Research I: Design
☐ 7411 Professional Socialization I: Introduction
☐ 7712 Clinical Education I
☐ 7141 Clinical Physiology I: Medical Physiology
☐ 7342 Patient Care Skills IV: Prosthetics and Orthotics
☐ 7171 Neuroscience I
☐ 7525 Clinical Research II: Statistics
☐ 7212 Clinical Pharmacology for Physical Therapists
☐ 7526 Clinical Research III: Evidence Based Practice
☐ 7311 Patient Care Skills I: Examination
☐ 7612 Clinical Problems I: Musculoskeletal I
☐ 7412 Professional Socialization IA: Prof. Dev. &Srvce
☐ 7192 Psychosocial Issues in Health Care
☐ 7151 Clinical Physiology II: Exercise Physiology
☐ 7532 Clinical Research IV: Research Project
☐ 7161 Clinical Kinesiology
☐ 7622 Clinical Problems II: Musculoskeletal II
☐ 7181 Neuroscience II
☐ 7653 Clinical Problems III: Neuromuscular I
☐ 7213 - Clinical Diagnostics for Physical Therapists
☐ 7321 Patient Care Skills II : Teaching & Learning
DPT III
☐ 7632 Clinical Problems III: Cardiopulmonary Care
☐ 7423 Professional Socialization II: Management
☐ 7643 Clinical Problems IV: Integumentary Care
☐ 7663 Clinical Problems VI: Neuromuscular II
☐ 7723 Clinical Education II
☐ 7673 Clinical Problems VII: Mgmt. of Multi-System Impairment
☐ 7433 Professional Socialization III: Professional Entry
☐ 7733 Clinical Education III (16 Weeks)
Have you consulted ALL appropriate course managers concerning this absence?
Yes
No
Please have ALL course managers initial and enter date of contact:
☐ Dr. Mary Ellen Franklin ____________
☐ Dr. Reza Nourbakhsh ______________ ☐ Dr. Andy Robinson __________
☐ Dr. Sue Ann Kalish _______________
☐ Dr. Stefanie Palma ________________ ☐ Dr. Don Walsh _____________
☐ Dr. Terrie Millard ________________
☐ Dr. Phil Palmer ___________________ ☐ Dr. Jenny Wiley ____________
☐ Dr. Carol Miller __________________
Have you consulted your academic advisor concerning this absence?
Yes
No
Date of contact with your advisor: ________________________
Provide the reason(s) for the proposed absence:
SPT Signature: ___________________________________________________ Date: ___________
For Administrative Use Only
(Do not write in this space)
Approved
Excused
Disapproved
Unexcused
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