Bachelor of Science in Nuclear Medicine Imaging Sciences Program Student Request for Leave of Absence From Clinic Form FacebookThis field is for validation purposes and should be left unchanged.Student Name(Required)Pick Student NameChantel ArnoldDestiney BauerZabrielle BradleyKenley BrumleyJordan CaplingerGlin Edwards, Jr.Patrick FahrenbruchAlaina GarciaCecilia HallMadison HansenRebecca HerdChase JenningsHaley JohnsonHelen McDonaldEvelyn MendezTara MooreKaitlyn MullenRebecca MunsonAbigail NewmanNichole Nolz (Martineau)India ObannonLeah PettyNathan PooleVictoria RedmonBrianna RidingsHermilo Rodriguez, IIIBrenique SheldonCarrie SmithAubree SmithHaven SmithStella SrisawangNathan TapiaEmma TennantAlexander TerryAple VangHannah WalkerDer YangAva ZevallosStudent Email(Required) Clinic Location City(Required)Pick Clinic Location CityAlexandriaBatesvilleBaton RougeConwayDallasJonesboroKearneyLafayetteLincolnLittle RockMobileNorthwest ArkansasOmahaPine BluffShreveportSioux FallsTulsaTylerWitchitaChoose Dallas Clinic(Required)Baylor Scott & White Cardiology Consultants of TexasBaylor Scott & White Medical Center — PlanoCardinal Health Nuclear Pharmacy ServicesChildren’s Medical Center of DallasUT Southwestern Clinical Ancillary Services ClinicUniversity of Texas Southwestern Medical Center of Dallas – PETVeterans Affairs North Texas Medical CenterChoose Jonesboro Clinic(Required)NEA Baptist Memorial HospitalRed River PharmacySt. Bernard's Medical CenterChoose Little Rock Clinic(Required)Arkansas Children’s HospitalCardinal Health Nuclear Pharmacy ServicesCHI St. Vincent Heart Clinic ArkansasCHI St. Vincent Infirmary Medical CenterJohn L. McClellan Memorial Veterans' HospitalUAMS Medical CenterChoose Northwest Arkansas Clinic(Required)Baptist Health Fort SmithCardinal Health Nuclear Pharmacy – FayettevilleCardinal Health Nuclear Pharmacy – Fort SmithHighland OncologyMercy Hospital Fort SmithMercy Hospital Northwest ArkansasNorthwest Medical CenterWashington Regional Medical CenterChoose Shreveport Clinic(Required)Cardinal Health — Nuclear Pharmacy ServicesCenter for Molecular Imaging and TherapyCHRISTUS Highland Medical CenterOchsner LSU Health System of North LouisianaOverton Brooks VA Medical CenterChoose Tulsa Clinic(Required)Ascension St. John Medical CenterCardinal Health Nuclear Pharmacy ServicesHillcrest Medical CenterSaint Francis HospitalChoose Tyler Clinic(Required)CHRISTUS Good Shepherd Medical Center — LongviewCHRISTUS Mother Frances Hospital — TylerLongview Regional Medical CenterNuTech Inc. — Radiopharmacy ServicesUT Health East Texas Cardiac PlazaUT Health TylerUT Tyler Health Science CenterChoose Alexandria Clinic(Required)Rapides Regional Medical CenterRapides Regional Medical Center — PETChoose Batesville Clinic(Required)White River Medical CenterChoose Baton Rouge Clinic(Required)Ochsner Medical CenterOchsner Medical Complex – The GroveCardinal Health — Nuclear Pharmacy ServicesChoose Conway Clinic(Required)Conway Regional Health SystemChoose Kearney Clinic(Required)Grand Island Regional Medical CenterKearney Regional Medical CenterChoose Lafayette Clinic(Required)Cardinal Health — Nuclear Pharmacy ServicesChoose Lincoln Clinic(Required)Bryan Health – East CampusBryan Health – West CampusBryan Pine Lake CampusChoose Mobile Clinic(Required)IonSouth Nuclear PharmacyMobile Molecular ImagingSpringhill Medical CenterChoose Omaha Clinic(Required)Bellevue Medical CenterCardinal Health — Nuclear Pharmacy ServicesChildren’s NebraskaNebraska Medicine OmahaChoose Pine Bluff Clinic(Required)Jefferson Regional Medical CenterChoose Sioux Falls Clinic(Required)Avera McKennan Hospital & University Health CenterCardinal Health — Nuclear Pharmacy ServicesNorth Central HeartChoose Wichita Clinic(Required)AMG Founders Circle PETAscension Via Christi St. FrancisCardinal Health — Nuclear Pharmacy ServicesI request the following number of hours of leave from my current clinical rotation site:(Required)Starting Date(Required) Month Day Year Both dates are inclusive. If request one day leave, starting date and ending date are the same.Ending Date(Required) Month Day Year Both dates are inclusive. If request one day leave, starting date and ending date are the same.The clinical supervisor has given me preliminary verbal approval for this leave request(Required) Yes No Do you have enough time accrued to compensate for this leave request?(Required) Yes, I Do No, I Do Not Since you do not have enough time accrued, state the reason for this request for leave in the box below (i.e. family emergency, job interview, etc.)(Required)I request the use of my "floating" day(Required) Yes No If you mark “Yes”, see the Student Handbook for the floating day usage policy and include the reason in the text box below.Indicate the reason from the Student Handbook that you are using your "floating" day(Required)I request the use of an "Inclement Weather" day(Required) Yes No Please provide a brief explanation regarding the inclement weather in your area.(Required)NOTE: Time off from clinic must be scheduled at least 16 working hours in advance in order to not constitute an occurrence. See: Student HandbookLeave request approvals will be emailed to you.CAPTCHA
