LEAVE OF ABSENCE/VACATION REQUEST

(* = required fields--be sure to fills these out or form will not submit properly)

Resident*: Resident Email*:

Days Requested (only include dates you'll be away--i.e. "To" is the last day you'll be away)

Please put in the total number of days you'll be away:
Number of Working Days

(Check all that apply)

Vacation with pay

Sick leave with pay

Holiday with pay

Balance without pay

Other:

Sick leave of more than 3 days must be accompanied by a physician's note.

Immediate Supervisor Supervisor's email

OR

Department Head Department Head's email

Notes/Other information:

Other Distribution:

Rita Misek
Esther Escotto
Chief Residents
Child Psych Chief Residents
Dr Eisen
Dr. Boland
Outpatient RCC--Dr. Guthrie
archive on our yahoo group

Other distribution (put in email addresses--look up resident emails here):

1.
2.
3.

An Email will be sent to each of the persons listed on the distribution list.

After you are through filling out form, please submit this by clicking the button below.