Leave Request LEAVE INFORMATIONName (First, Last)(Required) First Email Address(Required) Employee Type(Required)FacultyFellowTransplant FellowAPPStaffSupervisor(Required)Palvi SharmaAmir KazoryAlfonso SantosDavid WeinerAzra BihoracWei ShaoPinaki SarderJuan Manual Aranda-AmadorBenjamin ShickelBrooke ArmfieldDivya VellankiAhmed NaglahTezcan Ozrazgat BaslantiMark SegalAnindya Sankar PaulElizabeth Ann Nason PalmerAbdel AlliKyle ChambersUFID(Required) Total Number of Hours Requested (1 day=8 hours)(Required)Leave Start Date(Required) MM slash DD slash YYYY Leave End Date(Required) MM slash DD slash YYYY Select Type of Leave:(Required)VacationSickAcademicFMLALeave without PayOther (Please provide details in comments)Comments: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 Does this require clinic cancellation?(Required)N/AYesNoIf YES, what dates require clinic cancellation? Indicate AM/PM/both and Who/EPIC coverage each date.(Required)Provide several dates/times for makeup clinics (within +/- 2 weeks of cancelled clinics).(Required)Once Chief approval is received, you must also follow up with the clinic to ensure appropriate closures/make-ups have been scheduled. ACADEMIC 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 Signature(Required)
