Faculty and APP Leave Request Form Faculty & APP Leave Request Form Personal InfoWho is filling out?(Required) Myself (Faculty) Other Faculty First Name(Required)Faculty Last Name(Required)Faculty Email(Required) Submitter's First Name(Required)Submitter's Last Name(Required)Submitter's Email Who is your Chief/Supervisor?(Required)Irene MalatyGreg PontoneJames WymerGiri KalmangalamChristina WilsonIvan DaSilvaMichael JaffeeAnna KhannaLeave 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 following patient care below will be impacted? (Select ALL that apply.)(Required) Clinic Scheduled Day Service (Wards/Consults/Access Week) Resident Continuity Clinic Fellows Clinic C-ARM OR Clinic Scheduled DayWhich of the clinics will be impacted?(Required) Fixel NMH Both Clinics Inpatient Only Hailfax N/A Total Sessions Absent from Clinic(Required)Please 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?*(Required) Yes No Total Sessions Absent from Clinic Less than 60 Days Out(Required)Please 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. If more than 10 days are required, please put note in comment box. Clinic Make-Up Date 1(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 2(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 3(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 4(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 5(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 6(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 7(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 8(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 9(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Clinic Make-Up Date 10(Required) MM slash DD slash YYYY Clinic will be rescheduled for(Required) AM PM Non-Scheduled Clinic Patient CareWho will cover Access Week?(Required)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)?(Required)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?(Required)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?(Required)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?(Required)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)CommentsComments
