DEPARTMENT OF MEDICINE

DIVISION OF RHEUMATOLOGY

RHEUMATOLOGY FELLOW

LEAVE REQUEST

NOTE: All requests are tentative until approved by the Rheumatology Training Program Director.

Requests must be submitted on or before the 15^th of the month three months prior to the requested date of leave (e.g., October request is due by July 15^th). Requests submitted after the deadline will require the fellow to arrange coverage for clinic and call in order to accommodate a leave request.

Each line must be completed.

NAME: PGY 4 5 _______

DATE SUBMITTED:

FIRST DAY OF LEAVE:

LAST DAY OF LEAVE:

TYPE OF LEAVE: ANNUAL EDUCATIONAL^*:

APPROVED: DATE:

^*Must be accompanied by FELLOW’S REQUEST FOR PAYMENT OF EDUCATIONAL EXPENSES form if fellow is requesting travel reimbursement.

For Office Use

Distribution Initials

Fellow

Program Director

Division Chief

Dept. Business Officer

Dept Program Dir.

GME Office

2/9/00