Resident Planned Leave Request Form Resident Planned Leave Request IMPORTANT: All planned leave requests should be submitted a minimum of 2 weeks in advance. If submitted with less than 2 weeks notice, your request may not be processed. Name(Required) First Last Graduating Class(Required)R1R2R3InternEmail(Required) UFID(Required) Reason for Leave Request(Required) Beginning Leave Date(Required) MM slash DD slash YYYY Beginning Leave Date: 1/2 Day or Full Day(Required)AMPMAll DayEnding Leave Date(Required) MM slash DD slash YYYY Ending Leave Date: 1/2 Day or Full Day(Required)AMPMAll DayClinic Absence InformationPlease select the activity/activities you will miss:(Required) Clinic Sim Lab Course Activity Other Other(Required) Program Assistant(Required)Susan Beckett-YoungMichelle CooleyCourse InformationWill you miss more than one Didactic/Laboratory Course Activity?(Required)YesNoName of Didactic/Laboratory Course Activity 1(Required) Course Director1(Required)N/ACamargo, GelsonDelgado, AlexDias Ribeiro, AnaFigueiredoReis,AndreHussein,HindOliveira,DayaneCarvalhoPereira, PatriciaRocha, MateusSikand, RebeccaTerza, StephanieName of Didactic/Laboratory Course Activity 2(Required) Course Director2(Required)N/ACamargo, GelsonDelgado, AlexDias Ribeiro, AnaFigueiredoReis,AndreHussein,HindOliveira,DayaneCarvalhoPereira, PatriciaRocha, MateusSikand, RebeccaTerza, StephanieName of Didactic/Laboratory Course Activity 3 Course Director3N/ACamargo, GelsonDelgado, AlexDias Ribeiro, AnaFigueiredoReis,AndreHussein,HindOliveira,DayaneCarvalhoPereira, PatriciaRocha, MateusSikand, RebeccaTerza, StephanieName of Didactic/Laboratory Course Activity 4 Course Director4N/ACamargo, GelsonDelgado, AlexDias Ribeiro, AnaFigueiredoReis,AndreHussein,HindOliveira,DayaneCarvalhoPereira, PatriciaRocha, MateusSikand, RebeccaTerza, StephanieName of Didactic/Laboratory Course Activity 5 Course Director5N/ACamargo, GelsonDelgado, AlexDias Ribeiro, AnaFigueiredoReis,AndreHussein,HindOliveira,DayaneCarvalhoPereira, PatriciaRocha, MateusSikand, RebeccaTerza, StephanieIn any of the above activities, are you missing an exam?(Required) Yes No Name of Course Exam(Required) I have made all arrangements for all of the classes I will miss and/or the care of my patients.(Required) Yes No Comments (Optional - Please do not include confidential information here):
