subject_line
MCSO/OSU-CHS
Request for Vacation and Leave of Absence
Resident Name
*
Laurel Stacy, DO
James McKeehen, DO
Halie Muckelrath, DO
Jacinda (Jaci) Nuttle, DO
Chelsea Rommel, DO
Amanda Hale, DO
Stormy Walkup, DO
Jessica Anderson, DO
Kalli Reimer, DO
Robin Hoile, DO
Jacob Borgsmiller , DO
Machaille Borgsmiller, DO
George Russell, DO
Reason for Time off
*
Date requesting time off (six weeks notice required)
*
Date(s) requesting off
*
Approval of Attending Physician ________________________________________________________
d
ate
Approval of Program Director________________________________________________________
d
ate
Approval of DFMC office for schedule__________________________________________________
date
Residency Coordinator - schedule corrected____________________________________________
date
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