Leave Request
Intern Name:
DU ID:
Supervisor Name:
Site:
Graduate School of Professional Psychology
Internship Consortium
t.
2460 S. Vine St
Denver, CO
80208
Phone: 303-871-4737
Fax: 303-871-4220
Leave Type Start Date End Date Days Number of Hours Notes
Total
Comments:
Clinical coverage necessary?
Yes No
Staff Covering
Other coverage necessary?
Yes No
Staff Covering
Signature:
Authorized By:
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