Burrell College of Osteopathic Medicine – Excused Absence Request Form

Thank you.

Student Information
Student's Name*
Date of Request*
Date Format: MM slash DD slash YYYY
Student Class*
Please make sure you select the correct class.
Email*
Enter Email Confirm Email
Absence Details
Date From:*
Date Format: MM slash DD slash YYYY
Date To:*
Date Format: MM slash DD slash YYYY
Time
- Set Time
- All Day
Time from:

: HH

MM
Time to:

: HH

MM
Courses and Events Being Missed*
Students are required to list courses or events that will be missed during absence. Please list in detail the affected course or event, e.g., exam, lab, quiz, etc., and instructor or event contact.
Course or Event Time of Course or Event Instructor or Event Contact
Circumstances of Absence:*
Supporting Documentation
(i.e. Doctor's note, student organization conference registration, etc).
Drop files here or
Signature
Date
Date Format: MM slash DD slash YYYY

Course or Event	Time of Course or Event	Instructor or Event Contact

Excused Absence Request Form – 1st & 2nd Year