Name:

Clinical Assignment:

Date submitted:

Time requested from (Date):

To (Date):

Total Work Days Absent:

Total Hours Absent:

Annual Leave: ð                             Sick Leave: ð

Equivalent (comp.) Time: ð     For:

Other: ð     For:

ð     Category I Professional Leave—other

Purpose:________________________________________________________________

ð       CME

ð       Attendance at professional meeting

ð       Other—Specify: 

ð        

ð    Category II Professional Leave (performance plan required)

Purpose:_____________________________________________________________

ð       Presentation of funded and/or peer reviewed research

ð       Collaborative Research meetings

ð       Pharmaceutical Company Consultation (eg, new clinical trials)

ð       Service on National Board Examinations

ð       Service on Executive Boards of National Organizations (relevant to mission of department of psychiatry

ð       Grant Review Groups

Attending(s) Providing Coverage:

______________________________________________________________________

______________________________________________________________________

Approvals:

Clinical/Medical Director:_____________________________ Date: __________

Division Director: ____________________________________ Date: __________

Executive Medical Director: ___________________________ Date: __________

Department Chairman:_______________________________  Date: __________

Dean:______________________________________________  Date:___________