William Beaumont Hospital

Internal Medicine Residency Program

Conference Request Form

Step 1 Fill out form below, include conference information, registration, housing and syllabus information. This form
must be completed 8 weeks prior to the first day of the month you are taking conference.
Step 2 Have chief resident approve & sign.
Step 3 Have Dr. Shoichet approve & sign.
Step 4 **Please give signed form to Jeanne BEFORE you make plans for your trip.**

Name: _________________________________________ PGY: ______

Conference Name: _______________________________________________________

Conference Location: _________________________________________ CME Credits: _______

Dates of Departure and Return: _________-_________ Dates of Conference: ________-________

Rotation in which you will be taking conference: _____________________________

Will you be presenting at this conference: Y / N

Total days of conference (including travel days) you have taken this academic year: ______

Are you at risk during the month of this conference: Y / N

I have discussed this request with the other resident(s) who will be on service with me during the month of this
conference.

Signature of resident(s) on service with me: ___________________________________

___________________________________

I understand that approval of this conference does not guarantee that time off will be granted. I must also submit a
request for time off via e-mail 6 weeks prior to the beginning of the month in which I will be taking the conference.

_____________________________________ ____________
Signature of Resident Date

_____________________________________ ____________
Signature of Chief Resident Date

_____________________________________ ____________
Signature of Program Director/Associate Program Director Date