Time Away/Schedule Conflicts Request Form Time Away/Schedule Conflicts Request Form This form is for Course, Clerkship, or Elective Responsibilities. "*" indicates required fields Student Name* First Last Student Email* IU email address onlyCampus*Select CampusBloomingtonEvansvilleFort WayneIndianapolisMuncieGarySouth BendTerre HauteWest LafayetteSelect campus of the impacted course or rotationWhich Type of Request Are You Submitting?* Professional Development Opportunity Time Away/Schedule Conflict PDO is for Phase 1 Only Phase 1 students; e.g., attending a medical or scientific conference, etc. Hiddensecret-email Hiddensecond-secret-email Hiddenthird-secret-email Hiddenfourth-secret-email Hiddenfifth-secret-email Professional Development Opportunity SectionCourses Impacted*Select CourseTransitions IFoundations of Clinical Practice Year 1Human StructureMolecules to Cells & TissuesFundamentals of Health & DiseaseHost DefenseNeuroscience & BehaviorFoundations of Clinical Practice Year 2Cardiovascular & HematologyRenal & RespiratoryGastrointestinal & NutritionEndocrine, Reproductive, Musculoskeletal, and DermatologicPreparing for Professional Practice 1Preparing for Professional Practice 2I am currently on academic probation* No Yes Have you discussed this absence with site leaders from all affected courses?* Yes No You are required to speak with the course site leader(s) regarding the impact of the absence on coursework prior to submitting this form. Note: You are also responsible for talking with group members to obtain any material that was missed during the absence and rescheduling any missed clinical experience.Name of professional development opportunity* Starting Date* MM slash DD slash YYYY Ending Date MM slash DD slash YYYY Only if more than one dayHow many days away in total?*12345678910Rationale for attendance*If you are submitting this form past the deadline for PDO absences in this course, please include the reason it is late.Does this PDO request fall on an exam date? Yes No Time Away/Conflict Schedule SectionCourses/Clerkships/ElectivesWhich Phase Are You In?* Phase 1 Phase 2 Phase 3 Course Impacted*Please Choose a CourseTransitions IFoundations of Clinical Practice Year 1Human StructureMolecules to Cells & TissuesFundamentals of Health & DiseaseHost DefenseNeuroscience & BehaviorFoundations of Clinical Practice Year 2Cardiovascular & HematologyRenal & RespiratoryGastrointestinal & NutritionEndocrine, Reproductive, Musculoskeletal, and DermatologicPreparing for Professional Practice 1Preparing for Professional Practice 2*Please note that you must submit a separate request for each course.*Type of Program*Please Make a ChoiceClerkshipsElective or Critical Care SelectiveSub-I (Phase 3 Only)Transitions 2Transitions 3 (Phase 3 Only)STEPSIs this request for a Critical Care Selective? No Yes Phase 2 Clerkship*Please Choose a ClerkshipFamily MedicineInternal MedicineNeurologyOBGYN/AnesthesiaPediatricsPsychiatryRadiologySurgeryPhase 3 Clerkship*Please Choose a ClerkshipEmergency MedicineRadiologyPhase 3 Sub-I*Please Choose a Sub-IMedicineFamily MedicinePediatricsSurgeryOb/GynTitle of the Elective or Critical Care Selective* Course Director's Email Address* Course Director's Email Address* Time Away Requested From Course/Clerkship/Elective ResponsibilitiesStarting Date Absence* MM slash DD slash YYYY Ending Date Absence* MM slash DD slash YYYY Time Away - From:*7am8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pmTime Away - To:7am8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pmHow many total days will you be absent?*12345678910Reason for Absence*See the Schedule Conflicts, Absences, and Vacations Policy for further details. Please be aware that sensitive or personal information should NOT be uploaded as an attachment. Indicate below if any of the following apply to your request: This request falls on an exam date This request is bereavement related This request is related to a religious observance Upload Supporting Documentation Drop files here or Select files Accepted file types: pdf, doc, docx, key, ppt, pptx, odt, xls, xlsx, rtf, txt, pages, jpg, jpeg, png, gif, Max. file size: 32 MB, Max. files: 5. Is this time away request COVID-related?* Yes No Prefer not to answer CAPTCHAEmailThis field is for validation purposes and should be left unchanged.