Time Off Request Form

Students are personally responsible for attending and arriving on time to all required educational activities as specified by the block, course, or clerkship directors. All students are required to notify the MBS Program Administration of any planned or unexpected absences. For planned absences, students are required to complete this form as far in advance as possible. For unexpected absences, students should contact the MBS Program Administration at mbsprogram@nova.edu. Additionally, this form must be completed within 48 hours of the unexpected absence(s).

Please complete this form in its entirety. Once your request has been reviewed, you will be notified via your NSU email of the final decision and appropriate actions.

Time Off Request Information

Student Name:

Student N#:

Student Email:

Student Phone:

Time off requested:

Day(s)/Hour(s) requested:

Type of absence request:

Planned

Unexpected

Planned Absence:

Unexpected Absence:

Please provide a description of your absence request and indicate what measures you have taken or plan to take to minimize impacts of your absence.

Please indicate what required educational activities you will miss and include name(s) of your course director(s):

Upload any relevant documentation here(pdf,doc,docx):