Leave Request Leave Request Form LEAVE INFORMATIONName(Required) First Last UFID(Required) Leave Start Date(Required) MM slash DD slash YYYY Leave End Date(Required) MM slash DD slash YYYY Total Number of Hours Requested(Required)Select Type of Leave(Required)VacationSickFMLAAcademicJury DutyOtherCLINIC CANCELLATION INFORMATION*Cancellations <30 days = emergency only & require Chief approval *Cancellations 30-60 day window = require makeup clinics *Cancellations >60 days = follows annual Division cancellation allotment Does this require clinic cancellation?(Required)N/AYesNoIf YES, what dates require clinic cancellation? Indicate AM, PM or both for each date.Would you like to swap clinic session time so no cancellation will be recorded?(Required)N/AYesNoIf YES, provide preferred date(s):*Admin/clinic staff will follow up with you via e-mail regarding scheduled makeup clinics.COVERAGE INFORMATIONEPIC Inbasket Covered By:(Required) Inpatient Consults Covered By:(Required) SNF Covered By:(Required) ACADEMIC LEAVE INFORMATIONIf Applicable, Select Type of Academic Leave:N/AAcademic Conference/MeetingMeeting with State or Federal GovernmentGranting Agency Study SectionOtherWill the conference require a division reimbursement?N/AYesNoName of Conference: State Date: MM slash DD slash YYYY End Date: MM slash DD slash YYYY Signature(Required)
