Duty Change Request

Change of Schedule Form

Ventura County Medical Center Family Medicine Residency

Please use this form to submit schedule change requests.

Any changes involving AFMC half days must be submitted at least 4 weeks prior to the affected rotation.

Any changes not involving AFMC half days must be submitted at least 1 week prior to the affected rotation.

Requests will be reviewed on a weekly basis. Do not assume a request has been approved unless you receive confirmation from either the chiefs or the medical education staff.

Involved Residents

Please enter the names and email addresses of all residents involved.

Resident 1 Name*

Resident 1 Email*

Resident 2 Name*

Resident 2 Email*

Resident 3 Name

Resident 3 Email

Resident 4 Name

Resident 4 Email

Schedule Change #1

Date of Duty*

Name of Duty*

Resident Giving Up Duty*

Resident Taking Duty*

Schedule Change #2

Date of Duty

Name of Duty

Resident Giving Up Duty

Resident Taking Duty

Schedule Change #3

Date of Duty

Name of Duty

Resident Giving Up Duty

Resident Taking Duty

Schedule Change #4

Date of Duty

Name of Duty

Resident Giving Up Duty

Resident Taking Duty

Schedule Change #5

Date of Duty

Name of Duty

Resident Giving Up Duty

Resident Taking Duty

Schedule Change #6

Date of Duty

Name of Duty

Resident Giving Up Duty

Resident Taking Duty

Explanation:

Please enter here the reason behind your schedule change request, and any further information that might help us better understand the logistics.*

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