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Faculty of MedicineMD Undergraduate Program 006 C Student Absence Form
FOR REFERENCE, PLEASE REFER TO THE MD UNDERGRADUATE PROGRAMAT T E N DA N C E P OLI C Y & A B S E NCE P R O C E DU R E & A P P END IC E S A -C on Medicol
Date submitted (d/m/y): Date received (d/m/y):
STUDENT INFORMATIONStudent’s Last Name: First Name: Initial: UBC Student No.: Site (e.g. VFMP): Year/Class:
Email: Phone:
UNFORESEEN ABSENCE REPORTTo be submitted no later than 1 week after return from absence.
Start date of absence (d/m/y): Return to class date (d/m/y): Session(s) missed:
Name(s) of faculty/staff notified at the time of the absence, as specified in the Year Specific Contact document, A pp e n d i x A :
Reason for absence:
Actions to be taken to make up for anticipated missed learning & work, as discussed with contact(s) in the Year Specific Contactdocument, A pp e n d i x B :
NEGOTIATED ABSENCE REQUEST
To be submitted as soon as possible. If less than 4 weeks prior to the request, it may not be possible to process in time.Start date of absence (d/m/y): Return to class date (d/m/y): Reason for absence: Refer to Attendance Policy for Guidelines
Number of days absent this academic year to date (for all reasons):
Name of and email address(es) of faculty member(s) consulted in advance to discuss and approve plan for making up missedlearning, as specified in Year Specific Contact document, A pp e n d i x C :
Reason for negotiated absence (If confidential, please write “confidential” here, and request will be referred to OSA foradjudication):
Details of how missed session(s) including scheduled assessment(s) will be completed, after discussion with contact(s) as specifiedin Year Specific Contact document, A pp e n d ix C :
PLEASE SUBMIT THIS COMPLETED FORM TO THE FOLLOWING SITE- AND YEAR-SPECIFIC DESTINATIONS FO R N E G O T IA T E D A BS E NCE R E Q U E S T S , PL E A S E B E S U RE T O ‘ C O PY ’ AP P E N DI X C C O N T A C T ( S )
**ALL ABSENCES MUST BE REPORTED **IMP NMP SMP VFMP
Years 1&2 See On-line absence forms
Year 3 i m pr j h @ u v i c.ca [email protected] [email protected] [email protected]
Year 4 i m pr j h @ u v i c.ca [email protected] [email protected] y r4 .vfm p a bs e n c e@ub c.ca
Student Absence Form 2018-19 rev 15 August 2018
Faculty of MedicineMD Undergraduate Program Student Absence Form
SITE-SPECIFIC REVIEW OF NEGOTIATED ABSENCE REQUEST – FOR INTERNAL USE ONLYSTEP 1 (COURSE, CLERKSHIP DIRECTOR, ELECTIVE PRECEPTOR OR DESIGNATE)
Name of Step1 reviewer(s): Title: Email:
Date submitted (d/m/y): Date received (d/m/y):
□ Approval is recommended □ Approval not recommended
Recommended with the following changes:
Comments:
SITE-SPECIFIC REVIEW OF NEGOTIATED ABSENCE REQUEST – FOR INTERNAL USE ONLYSTEP 2 (DEAN’S OFFICE – ASSISTANT DEAN OR DESIGNATE)
Name of Step 2reviewer: Title: Email:
Date submitted (d/m/y): Date received (d/m/y):
☐Approved ☐Not Approved Reason: ☐ Duration ☐ Year Absences ☐ Academic
☐Approved with the following changes:
Comments:
STUDENT NOTIFICATION
Date of notification (d/m/y): Notified by:
TEACHER/COURSE NOTIFICATION
Date of notification (d/m/y): Notified by:
Faculty/staff notified:
Student Absence Form 2018-19 rev 15 August 2018