MCSO/OSU-CHS
Request for Vacation and Leave of Absence
*
Resident Name
Monica Woodall, DO
Michael Roach, DO
Mike Boger, DO
Robert Gispanski, DO
Thomas Jarvis, DO
Andrew Hamill, DO
Alex Roby DO
Clay Garrett DO
Robert Moody DO
Tim Newton DO
Reason for Time Off
*
Date requesting time off (six weeks notice required)
*
Dates Requested Off
*
Approval of Rotation Physician _____________________________________________________
date
Approval of Human Resources______________________________________________________
date
Approval of Medical Records________________________________________________________
date
Approval of Assistant PD/Chief Resident for Call_________________________________________
date
Approval of Program Director________________________________________________________
d
ate
Approval of DFMC office for schedule__________________________________________________
date
Residency Coordinator - schedule corrected____________________________________________
date
*
Indicates Response Required