Endocrinology Leave Request Faculty, Fellow, APP & Staff Leave Request Form This leave request form is for ALL employees within the Division of Endocrinology, Diabetes, and Metabolism. LEAVE INFORMATIONName(Required) First Last Email Address(Required) Employee Type(Required)FacultyFellowObesity Medicine FellowAPPStaffSupervisor(Required)SelectAshley PankeyKenneth CusiSushma KadiyalaAmy SheerTroy DonahooHans GhayeeCharlie KhemtongPeter StacpooleUFID(Required) Total Number of Hours Requested(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 or both for each date.If applicable, provide several dates/times for makeup clinics (within +/- 2 weeks of cancelled clinics).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)
