Clinical Faculty Leave Request Clinical Faculty Leave Request Form "*" indicates required fields Leave InformationName* First Last Email* UFID*Leave Start Date* MM slash DD slash YYYY Date Returning to Work* MM slash DD slash YYYY Total Number of Hours Requested*Select Type of Leave:*SickVacationFMLAAcademicJury DutyIf this is a regarding a new FMLA event that has not been approved, please submit the initial intake form at https://benefits.hr.ufl.edu/time-away/fmla/fmla-preliminary-request-form/ Clinic 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 – if you are uncertain as to whether this cancellation will exceed your FY allotment, please email MedPulmonaryStaff@medicine.ufl.edu before submitting to inquire how many cancellations you have remainingDoes this require clinic cancellation?*N/AYesNoIf YES, what dates require clinic cancellation? Indicate AM, PM or both for each date.If applicable, provide several dates/times for makeup clinics so we can coordinate with clinic (within +/- 2 weeks of cancelled clinics).*Admin staff will follow up with you via e-mail regarding scheduled makeup clinics.Who will cover your EPIC inbox during your leave?*Service Coverage InformationAre you on service during this leave request?*NoMICUConsult 1Consult 2/SelectIf you are on service, have you submitted the appropriate swaps?*YesNoN/AAcademic Leave InformationSelect 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:Start Date: MM slash DD slash YYYY End Date: MM slash DD slash YYYY Required SignaturesType your name below to confirm*CAPTCHA
