Resident Leave Request Form

Please use the below form to request leave time. Requests will be reviewed by the Administrative Chief Residents and Program Directors. Completion of this form is required to schedule any leave. Please review the vacation policy from the resident handbook when requesting leave. You must discuss potential leave with the service scheduler and chief resident of the service on which you will be rotating at the time of your absence. Maximum total business days per year for leave: personal (10); course/conference (5); professional including fellowship interviews (5).

Name*
Email address*
Leave Type*
- Personal
- Conference
- Professional
Leave Details
For conference and professional leave requests, please provide further information.
Leave Begin Date*
MM slash DD slash YYYY
Leave End Date*
MM slash DD slash YYYY
Rotation*
(at time of requested leave)
Other residents on service*
Notes
Please use this field if there are special circumstances associated with this leave request.
Leave Request Requirements
Please confirm below.
- Request sent to administrative chief?
- No other residents from class taking leave at same time
- For conferences / courses - discussed funding with PI?
- Please remember to add the time off to the master calendar
- Please log time off in New Innovations
The vacation request will be considered and we will let you know if there is an issue.