Faculty Leave Request

Faculty Leave Request Form

  • LEAVE INFORMATION

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • *If regarding FMLA, email Chris Pintado
  • 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
  • *Admin staff will follow up with you via e-mail regarding scheduled makeup clinics.
  • INPATIENT COVERAGE INFORMATION

  • *If "Yes", must submit OpenTempo swap request before leave is approved
  • ACADEMIC LEAVE INFORMATION

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Required Signatures