Faculty Leave Request Form Faculty Leave Request Form Name?:* First Last Faculty E-mail Address?:* Leave Type?:*VacationSickAdministrativeProfessional DevelopmentDecember PersonalIf this is a request for professional leave and you are requesting expenses, you must request these separately. Please provide details for professional development leave; administrative leave; or partial days:Leave Begin Date?:* MM slash DD slash YYYY Return-to-Work Date?:* MM slash DD slash YYYY Does the leave occur on a scheduled service/call day?:*YesNoIf you chose "yes" for the question above, who will cover your missed service/call hours?: If you are a medical director or have administrative duties, who is covering as your designee while you are out?Available for contact via:*Phone and e-mailPhone onlyE-mail onlyUnavailableOPTIONAL: Add your name and e-mail address below if you are submitting this leave request form on behalf of the requesting faculty member.Name First Last Email NameThis field is for validation purposes and should be left unchanged.
