Forms, Policies and Procedures
Forms, Policies and Procedures for Medical School Students
This page contains links to the most common forms used by students at the UC Riverside School of Medicine.
The forms are all editable PDFs which you can download to your computer, fill out, save, then print or send electronically. Please note that the editable function may not work within your browser. To save the files, right-click on the link and select the "save file" option.
If you need a form that is not listed on this page, please contact the Office of Student Affairs between the hours of 8 a.m. to 5 p.m., Monday through Friday.
Approved Absence Request
Use this form to request time off for doctor's appointments, conference attendance, or other personal events.
Medical Leave of Absence (MLOA) Request
Use this form to request extended time off due to health and/or medical needs.
Return from Medical Leave of Absence (MLOA) Request
Use this form to request permission to return after a medical leave of absence.
Leave of Absence (LOA) Request
Use this form to request extended time off for reasons other than health/medical needs.
Return from Leave of Absence (LOA) Request
Use this form to request permission to return after a non-medical leave of absence.
Leave of Absence Extension Request (LOA)
Use this form to request additional time off during an approved leave of absence.
Forms for Current Students
Document Request Form - Current Students
Use this form to request documents such as transcripts, enrollment verification and letters of good standing.
Letter of Recommendation Request Form
Use this form to request a Dean's Letter of Recommendation for fellowships, scholarships or other educational opportunities.
Name Change or Correction Form
Use this form to request a change of name on all SOM student records in connection with a legal name change.
Health Clearance Update for Returning Students Form
These are the vaccinations and immunizations required annually for all students.
Forms for Incoming Students
HIPAA Release Form
This confidentiality statement details that non-workforce members abide by the regulations of the federal Health Insurance Portability and Accountability Act (“HIPAA”), the California Confidentiality of Medical Information Act and other federal and state laws and regulations.
Vaccination and Immunization Requirements for Incoming Students
These are the vaccinations and immunization required of all incoming medical students prior to the start of Orientation Week.
Medical Student Insurance Information Form
This form is to be used to detail the insurance information for students of the UCR School of Medicine.
Provision of Medical Treatment to UCR SOM Students by UCR SOM Faculty
Use this form when being treated by a UCR clinical faculty member to clarify if the health issue is of a sensitive or non-sensitive nature.
Exposure to Blood Brochure - What Healthcare Personnel Need to Know
This brochure on occupational exposures to blood is produced by the Centers for Disease Control and Prevention and the Department of Health and Human Services. By clicking the link, you will be taken to the CDC website to view the PDF.