Faculty Leave Request Form » Department of Neurology » College of Medicine

Faculty Email Address:*

Email Address of Person Submitting Form*

Type of Leave*

Purpose of Professional Development Leave?

Be sure to provide dates of the professional development event and any associated travel dates.

Request for Travel Approval

Begin Date*

End Date*

Total Hours Absent from Work*

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.

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.

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**

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**

Comments

Click here to fill out the Travel Expense Form