Faculty and AAP Leave Request Form Faculty and AAP Leave Request Form Personal InfoWho is filling out?(Required) Myself (Faculty) Other Faculty First Name(Required)Faculty Last Name(Required)Faculty Email Address(Required)Submitter's First Name(Required)Submitter's Last Name(Required)Submitter's Email Address(Required)Leave InfoType of Leave(Required) Annual Leave (Vacation, Personal) Sick Leave Professional Development December Personal Total Hours Absent(Required)Purpose of Professional Development?(Required)For Professional Development(Required) Travel Authorization is Required Start Date(Required) MM slash DD slash YYYY Start Time(Required) Hours : Minutes AM PM AM/PM End Date(Required) MM slash DD slash YYYY End Time(Required) Hours : Minutes AM PM AM/PM Patient CareWill Patient Care be impacted(Required) Yes No Which of the patient care below be impacted?(Required) Clinic Scheduled Day Access Week Service (Wards/Consults) Resident Continuity Clinic Fellows Clinic C-ARM OR Clinic Scheduled DayTotal Sessions Absent from ClinicPlease indicate absence in number of clinic sessions missed. A clinic is 4 hours long so one missing clinic = 1 session A clinic missing 2 hours of a four-hour clinic = .5 session.Is this Clinic Scheduled Day(s) Less Than 60 Days Out?* Yes No Clinic Make-Up Date 1 MM slash DD slash YYYY Clinic Make-Up Date 2 MM slash DD slash YYYY Clinic Make-Up Date 3 MM slash DD slash YYYY Non-Scheduled Clinic Patient CareWho will cover access week?Provide makeup dates to cover the number of access clinics that will be closed. Dates may expand over multiple weeks based on availability.Who will cover Service (Wards/Consults)?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)Who will cover Resident Continuity Clinic?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)Who will cover fellows clinic?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)Who will cover C-ARM?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)Who will cover OR?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)CommentsCommentsCaptchaCAPTCHA
