DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
FACULTY/RESIDENT
LEAVE REQUEST FORM
(Vacation/Sick/CME/Travel/Administrative)
Date Submitted: _________________________
Name: _____________________________________________________________
Dates (Inclusive) Requested:
____________________________through____________________________
Total Number of Days: ____________
Type of Leave: _____________________
Eight Weeks Advance Notice: Yes
________ No ________
Justification for Late Request:
_________________________________________________
________________________________________________________________________
|
Residents Only: Rotation:
____________________________________________________ Administrative Leave or Travel: ________________________________ ______________________________ Residency
Director
Date |
|
Faculty Only: Patient Coverage Will be Provided by: ______________________________ Signature of Person Agreeing to Coverage: _________________________ Administrative Leave or Travel: ______________________________
______________________________ Department
Chairman Date |
REVIEWED/APPROVED BY SCHEDULING COMMITTEE:
_________________________________________ _______________________
NAME DATE
Approved Leave Request Form Copied to:
____________________Faculty/Resident
06/24/99-kaberry