Time Away/Schedule Conflicts Request Form Student Name* First Last Student Email* IU email address onlyCampus*Select CampusBloomingtonEvansvilleFort WayneIndianapolisMuncieGarySouth BendTerre HauteWest LafayetteWhich Type of Request Are You Submitting?*Professional Development OpportunityTime Away/Schedule ConflictPhase 1 students; e.g., attending a medical or scientific conference, etc.secret-email second-secret-email third-secret-email fourth-secret-email fifth-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 DermatologicI am currently on academic probation*NoYesHave you discussed this absence with site leaders from all affected courses?*YesNoYou 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* Date Format: MM slash DD slash YYYY Ending Date Date Format: 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.Time Away/Conflict Schedule SectionCourses/Clerkships/ElectivesWhich Phase Are You In?*Phase 1Phase 2Phase 3Course 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 DermatologicType of Program*Please Make a ChoiceClerkshipsElectivesSub-I (Phase 3 Only)IntersessionsTransitions 2Transitions 3 (Phase 3 only)Phase 2 Clerkship*Please Choose a ClerkshipAnesthesiaFamily MedicineInternal MedicineNeurologyObstetrics/GynecologyPediatricsPsychiatrySurgeryPhase 3 Clerkship*Please Choose a ClerkshipEmergency MedicineRadiologyPhase 3 Sub-I*Please Choose a Sub-IMedicineFamily MedicinePediatricsSurgeryOb/GynTitle of the Elective*Course Director's Email Address* Course Director's Email Address* Time Away Requested From Course/Clerkship/Elective ResponsibilitiesStarting Date Absence* Date Format: MM slash DD slash YYYY Ending Date Absence* Date Format: 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. Upload Supporting Documentation Drop files here or Accepted file types: pdf, doc, docx, key, ppt, pptx, odt, xls, xlsx, rtf, txt, pages, jpg, jpeg, png, gif. This iframe contains the logic required to handle Ajax powered Gravity Forms.