Faculty Leave Request

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Name

Purpose for request

Attend a meeting Vacation Cancel/Alter Clinic Other

Meeting/Course Details:

Course/Meeting Name:

Location:

Leave Begin Date

Leave End Date

Return to Work Date:

Request Funding By Department

Yes No

Vacation Request in conjuction with meeting?

Yes (Complete next section) No

Vacation Request:

Beginning Date:

End Date:

Requests to Cancel/Modify Clinics:

Cancel Clinics - Date & Reason

Other Leave Request Details:

Other Leave Request detail (Military, Family, Civil, etc.)

Scheduling Instructions. Please detail if OR and clinic schedules will be impacted and who will be covering for you if on call.

Please initial and date below to affirm that the information entered is accurate and that you have made arrangements for any coverage that is needed. You will be asked to sign a hard copy of this form later.

Initials

Date Submitted

University of Virginia Health System