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    441 Resident Leave Request

    Uploaded by

    Randy Bornmann
    This form must be completed at least 4 weeks in advance for planned absences during clinic rotations and 2 weeks in advance for electives or selectives. Failure to complete the form will result in an unexcused absence, loss of pay, possible lack of training credit, and discipline. The resident must have all administrative items current and obtain signatures from their attending physician, chief resident, and program director to approve the leave request. Back up documentation is required for certain reasons like exams, conferences, or interviews.

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    441 Resident Leave Request

    Uploaded by

    Randy Bornmann
    32 views1 page
    This form must be completed at least 4 weeks in advance for planned absences during clinic rotations and 2 weeks in advance for electives or selectives. Failure to complete the form will result in an unexcused absence, loss of pay, possible lack of training credit, and discipline. The resident must have all administrative items current and obtain signatures from their attending physician, chief resident, and program director to approve the leave request. Back up documentation is required for certain reasons like exams, conferences, or interviews.

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    leave

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    441 Resident Leave Request[2]

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    This form must be completed at least 4 weeks in advance for planned absences during clinic rotations and 2 weeks in advance for electives or selectives. Failure to complete the form will result in an unexcused absence, loss of pay, possible lack of training credit, and discipline. The resident must have all administrative items current and obtain signatures from their attending physician, chief resident, and program director to approve the leave request. Back up documentation is required for certain reasons like exams, conferences, or interviews.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views1 page

    441 Resident Leave Request

    Uploaded by

    Randy Bornmann
    This form must be completed at least 4 weeks in advance for planned absences during clinic rotations and 2 weeks in advance for electives or selectives. Failure to complete the form will result in an unexcused absence, loss of pay, possible lack of training credit, and discipline. The resident must have all administrative items current and obtain signatures from their attending physician, chief resident, and program director to approve the leave request. Back up documentation is required for certain reasons like exams, conferences, or interviews.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    University of Miami/JFK Medical Center Palm Beach Regional GME Consortium

    Internal Medicine Residency

    RESIDENT LEAVE REQUEST FORM

    ThisformMUSTbecompleted: (duringclinic)atleast4weeksbeforeanyplannedabsence
    (duringelectives/selectives)atleast2weeksbeforeanyplannedabsence

    Failuretocompletethisformwillresultinanunexcusedabsencefromtheresidencyprogram,lossofsalaryforthedates
    involved,possiblelackoftrainingcreditforthemissedperiod,andpotentialdisciplinaryaction.
    AllAdministrativeitems(dictations,evaluation,dutyhoursandotherforms)mustbecurrent.

    ResidentName:________________________________________________________________DateofRequest:________________

    Leave:____/____/____Thru:____/____/____ReturntoWorkDate:____/____/____TotalDaysRequested:__________

    RotationNameandHospital(JFKorVAMC):_____________________________________________________________________

    ReasonforAbsence:

    VacationPersonalTimeOffExamEducationalConferenceJob/FellowshipInterviewOther

    *Backupdocumentationrequiredforexams,educationalconferences,interviewsandother

    NameofExam:______________________________________________ExamLocation:__________________________________

    InterviewLocation:__________________________________________InterviewCity/State:______________________________

    NameofConference:_________________________________________ConferenceLocation:_____________________________

    Other(Reason):_______________________________________________________________________________________________

    Attending Physicians Signature: ________________________________________________ Date: __________________________

    Clinic Blocked Signature (If Applicable): __________________________________________ Date: __________________________

    Chief Residents Signature: _____________________________________________________ Date: __________________________

    Program Directors Signature: __________________________________________________ Date: ___________________________

    Change approved: Yes NO Reason: ___________________________________________________________________

    Date Clinics Notified: ___________________________________________________________________________________________

    Amion Updated: Date: Initials: ______ Master Spread Sheet Updated: Date: ___Initials: ______

    Clinic Manager Notified: Date: ________Initials:______ Resident Notified of Approval: Date: ___Initials: ______

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