USF/COM  GRADUATE MEDICAL EDUCATION RESIDENT LEAVE-OF-ABSENCE REQUEST FORM
(See current year Resident Handbook for rules on leave-of-absence)
Department/Sub-Specialty:				Date:
Name:			PGY Level:	SSN:
Reason for Leave:
Period of leave requested:		through
	Compensated Leave **				Uncompensated Leave
Types of Leave Being Used	Sick Leave (Prior Year) *	Sick Leave (Current Year)	Annual Leave (Prior Year) *	Annual Leave (Current Year)	From	To
Maternity Leave (max. 12 weeks)
Paternity Leave (max. 12 weeks)
Family Leave	N/A		N/A
Military Leave  (max. 17 days)	N/A		N/A
Other ***	N/A		N/A
* Maximum of one week Annual Leave and any unused Sick Leave can be carried over from the prior year on a "Planned Parental Leave of Absence"
(Maternity/Paternity) ONLY.	This must be approved PRIOR to use and rotation hospital must be notified  -  See Resident Handbook.
** Attach copy(s) of prior year/current year leave record(s) to document compensated leave.
*** Purpose of "Other" leave:
I UNDERSTAND THAT MOONLIGHTING OR LOCUM TENENS ACTIVITY WHILE ON A LEAVE OF ABSENCE IS NOT ALLOWED.
		YES: _______	NO: _______
Signature of Resident:				Date:
Approvals:
Program Director:				Date:
Associate Dean, G.M.E.:				Date:
Distribution of approved copies:
1) GME Coordinator	2) Departmental payroll certification contact person:			3) Business Office - MDC Box 66		4) GME Office - File