Absence Form » Mobile Outreach Clinic » College of Medicine

This form is used for Care Coordinators to report their absences to their LCs and to DOCOM.

Your Name:(Required)

Who is your usual LC for the shift you are missing?(Required)

Please select “N/A” only if you are reporting a Monthly Huddle absence.

UFL Email(Required)

What are you missing?(Required)

Please indicate the type of shift or event you will be missing.

Date You Will Be Missing(Required)

Please indicate the date that you will be missing your shift.

Your Original Clinic Shift:(Required)

Please indicate your original shift (the shift you are missing).

Your Original Clinic Time:(Required)

Please indicate the time of your clinic shift (the shift you will be missing).

Your Original Office Shift:(Required)

Please indicate the day of your original office shift (the shift you are missing).

Your Original Office Time:(Required)

Please indicate the time of your original shift (the shift you are missing).

Care Coordinator Covering for You:(Required)

Please indicate the name of the Care Coordinator who will be covering your clinic shift while you are absent. Of note, first semester CCs cannot cover your clinic shift.

Will you be swapping shifts with the Care Coordinator listed above?(Required)

Date of the New Shift(Required)

What is the exact date of the new office or clinic shift you are switching into? Please keep in mind that you can only go to this shift if there is space for you. Contact the LC at the shift you want ahead of time to confirm before picking a day on this form to come in to do your shift.

Day of the New Office Shift:(Required)

Please indicate the week day of the new office shift you will be attending.

Time of the New Office Shift:(Required)

Please indicate the time of the new office shift you will be attending.

Day of the New Clinic Shift:(Required)

Please indicate the week day of the new clinic shift you will be attending.

Time of the New Clinic Shift:(Required)

Please indicate the time of the new clinic shift you will be attending.

Who is the LC for the new office or clinic shift you are taking?(Required)

Please consult the schedule in the Teams General Channel to see which LC is assigned to the new shift you’re attending to make up your office shift absence, or as part of a clinic shift swap with another CC. Note you should have also already Teams messaged the LC to make sure there is space for you to attend their shift, and gotten approval from them, before submitting this form.

Description of Absence(Required)

Please give a detailed description of why you will be absent. Remember that acceptable excused absences for office/clinic shifts or Monthly Huddles are death in the family, illness, religious holiday, wedding, doctor’s appointment, interviews, or exams that directly overlap with the time of the shift.

Evidence of Absence(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 125 MB.

Please provide any evidence that you might have of your absence. Example: Screenshot of an exam date, plane ticket, etc.

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