This form is required of all students missing any required program activity and must be
submitted to each Course/Activity Director for all absences.
Refer to the OT Program Student and Student Fieldwork Handbooks for the Program’s absence policies, including consequences for repetitive requests and unexcused absences.
If on a Supervised Clinical Practice Experience, students must inform and make arrangements
with their Clinical Preceptor for all missed activities and indicate that arrangement on this form.
All fields marked with asterisk (*) are required.