Burke Rehabilitation Hospital

PM&R Residency Program

Resident Vacation Request Form
Resident Name: _________________________________
Assigned Service:________________________________
Vacation Dates Requested:_________________________
Dates Request Submitted: _________________________
Program Director Approval Date: ___________________

Resident Signature: ______________________

Service Attending Physician Signature: ____________________
Program Director Approval: ________________________

Note:
All vacation requests should be made a minimum of 3 months in advance. Services cannot
guarantee requests received with less than 3 months notice. As well, decisions regarding
approval by services for vacation requests should be given to the applicant within 2 weeks of
the date of submission.
It is the residents responsibility to ensure that the appropriate supervisors sign the
vacation request form before submitting to the Program Director or designate.

Revised on 5/2016
MLK/Approval AFB