Unscheduled Time Off Request

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The resident that is requesting the change in schedule should complete this form in its entirety. Use this form to request a schedule change for any reason including: day off, educational leave, fellowship interviews, religious holidays, etc. For call or shift swaps, please use the "Call or Shift Swap Request Form".

Please begin by entering your UB e-mail address below:

Email *

First and Last Name: *

Your cell phone number:

What module are you requesting time off from? Please include module number as well. (ie: Night float @ Mercy, Module 10)

Time off start date: *

YYYY

Time off end date: *

YYYY

Will you be leaving town? *

Yes

Are you on call or primary/secondary backup? *

Yes

Do you require backup coverage or a "switch partner"? (REQUIRED for anyone on a floor rotation, ambulatory module, or primary/secondary backup) *

Yes

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