Faculty Leave Request Form Faculty Leave Request Form Please fill out the following Leave Request form. "*" indicates required fields Faculty Name* First Last Faculty Email Address:* Name of Person Submitting Form* First Last Email Address of Person Submitting Form* Type of Leave*Annual LeaveSick LeaveProfessional DevelopmentDecember Personal LeavePurpose of Professional Development Leave?Be sure to provide dates of the professional development event and any associated travel dates.Are Travel and Expenses Required?* Yes No If yes, please submit Request for Travel Approval form if you have not already done so, upon submission of this form.Request for Travel ApprovalBegin Date* MM slash DD slash YYYY Begin Time* Hours : Minutes AM PM AM/PM End Date* MM slash DD slash YYYY End Time* Hours : Minutes AM PM AM/PM Total Hours Absent from Work* Will patient care be impacted?* Yes No Clinic Scheduled Day?* Yes No Total Sessions Absent from Clinic Please indicate absence in number of clinic sessions missed. A clinic is 4 hours long so one missing clinic = 1 session, missing 2 hours of a four hour clinic = .5 session.Is this Clinic Scheduled Day(s) Less Than 60 Days Out?* Yes No List Clinic Makeup Date for each clinic that is less than 60 days out.*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Additional dayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920-Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Makeup dates need to be prior to requested leave dates. Patients are to be seen prior to original appointment date. Unplanned absences will be made up on the next available administrative Are you on Access Week?* Yes No List dates for Access Makeup Week*Provide makeup dates to cover the number of access clinics that will be closed. Dates may expand over multiple weeks based on availability.Are you on Service (Wards, Consults)?* Yes No Who will cover for you?Provide type of service, full names, and associated dates and times for those providing coverage. **Please note it is the faculty’s responsibility to arrange coverage**Are you covering Resident Continuity Clinic?* Yes No Who will cover for you?*Provide type of service, full names, and associated dates and times for those providing coverage. **Please note it is the faculty’s responsibility to arrange coverage** Are you covering Fellows Clinic?* Yes No Who will cover for you?Are you covering C-ARM?* Yes No Who will cover for you?Comments Click here to fill out the Travel Expense Form CAPTCHA
