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Department of Neurology College of Medicine

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Faculty & APP Leave Request Form

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Personal Info

Who 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)

Leave Info

Type 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

End Date(Required)

MM slash DD slash YYYY

End Time(Required)

Hours

:

Minutes

AM/PM

Patient Care

Will 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 Day

Which 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 Care

Who 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)

Comments

Comments

Department of Neurology College of Medicine

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Physical Address: 1505 SW Archer Road
Gainesville, FL 32608
Phone: (352) 294-5000

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