ED Schedule Request Form
2020-2021

ED Schedule Request Form for Residents
This form is only for residents requesting days off during Sinai Adult ED, Elmhurst Adult ED, MS BI ED, or Sinai Peds ED blocks.

If you would like to request time off for any other block (including off-service rotations), 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, please feel free to contact the appropriate ED chief:
Sinai adult ED: Arjun Prabhu | arj.prabh@gmail.com
Elmhurst adult ED: Ellie Roberts | robertse7777@gmail.com
BI adult ED: JD Ditkowsky | jaredditko@gmail.com
Sinai peds ED: Wendy Lin | wendyxlin@gmail.com
Email *
Your first and last name *
Residency program *
Level *
Site *
Block *
GUIDELINES REMINDER (*outlined in Survival Guide)

Four week rotation permits:
(1) One request with a maximum duration of 72 hours (i.e. three days or six 12-hour shifts)
(2) A second request of one 12-hour period .The second (12 hr) request cannot be added to the primary request to extend it.

Two week rotation permits:
(1) One single request with a maximum duration of 48 hours (i.e. two days or four 12-hour shifts).

Schedule requests that do not conform to these rules may NOT be considered.

Of note, due to scheduling constraints, residents who make schedule requests may not be granted the usual number of weekends off.

If you believe you require time off in excess of what is permitted above for academic or personal reasons, you will need approval in email form from the ED Program Director (If EM) or your service's chief (if not EM) sent to the site-specific chief (see top).

Please do not request time off to extend your vacation (pre or post). It is unfair to your colleagues and penalizes them with a worse schedule.
YOUR REQUEST(S) Please use this format: MM/DD/YY time - MM/DD/YY time example: "12/3/18 0700 - 12/5/18 0700." (This equates to 12/3 day&night, 12/4 day&night off. You may be scheduled to work 12/5 at 7am). *
Reason for request
Clarification / comments? If entering multiple requests, please let us know here how to prioritize them.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy