ED Schedule Request Form for Residents
This form is for residents requesting days off during Sinai ED, Elmhurst ED, or Peds ED blocks ONLY. If you would like to request time off for any other block (including off-service rotations such as EMS, Ultrasound, ICU, or Medicine), please DO NOT fill out this form. Instead, refer to the Off-Service Rotation section of the SinaiEM Survival Guide for instructions on how to make an off-service schedule request. If you have questions about this, please feel free to contact the ED chiefs.
First and Last Name
The schedule request deadline for Block 6 is September 10th at midnight.
All schedule requests must be made 10 weeks before the start of each block to be considered.
To request 4 days off or more in a row, you must first email our Program Director, Dr. Kaushal Shah, at
for approval. Once you have approval, please contact the appropriate site chief.
Please list the dates off that you are requesting in mm/dd format separated by commas. Please indicate whether you want DAY or NIGHT off. For instance: 3/11 NIGHT, 3/12 DAY and NIGHT, 3/13 DAY. Do not include any other information (you will have an opportunity to elaborate further below).
What is the reason for your request?
If you are submitting multiple requests, how would you like us to prioritize this one? If this is your only request, skip this question.
This is the MOST important request. Please give me these dates first.
This is the SECOND most important request.
This is the THIRD most important request.
This is the LEAST important request and can be sacrificed for the others.
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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