Endocrinology Leave Request Faculty, 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)FacultyAPPStaffSupervisor(Required)SelectKenneth CusiTroy 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) Reset signature Signature locked. Reset to sign again
