ࡱ> \ ]bjbj ;0jbjb f448L$pT$(DDD2$4$4$4$4$4$4$$a&)xX$D|""DDX$m$D^82$D2$:",R#K^R" $$0$#R)H)R#)R#DDDDDDDX$X$<fDDD$DDDD)DDDDDDDDD4B v:  LEAVE REQUEST FORM I, ____________________________________, hereby apply for leave from my regular duties at the Department of Ophthalmology, for the following reason: DATE OF LEAVE: Start date: ___________________________ End date: _______________________  Vacation  Float/Day Off in Lieu (if available) as per article 13 of PARA Agreement Program Administrator will record and apply Float/Flex/In Lieu days prior to applying vacation days.  Elective Leave: Name of elective: ___________________________________________________ Location/preceptor(s): _______________________________________________ __________________________________________________________________ If Out-Going: Authorization granted through PGME: ____ YES ____ NO (Out-Going Elective Registration Forms must be completed and returned to the PGME office a minimum of 10 weeks prior to the start date of the elective. Forms are available in the OVS website  HYPERLINK "/ophthalmology/forms-cabinet" Forms Cabinet) Is elective: _____ Accredited _____ Non-accredited  Other (conference, interviews, sick, etc.): Please specify: __________________________________________________________________ *Please note that educational leaves such as review courses must be requested using the PGME leave form found in the  HYPERLINK "/ophthalmology/forms-cabinet" Forms Cabinet SERVICE COMMITMENTS: Name of Rotation in which leave occurs: _______________________________________ Scheduled on-call/presentations formally reorganized: _____ n/a _____ YES _____ NO Date of Request: _______________________________________________ Signature of Applicant: __________________________________________ APPROVAL: Chief Resident: ________________________________________________ Program Director: ______________________________________________ ALL leave requests must be approved with appropriate advance notice and additional approvals, as necessary prior to making any travel arrangements. A copy of this form, with signatures of the Chief Resident and Program Director, will be returned to the resident indicating approval of the leave. *Leave Still AvailableVacation:Flex: /3Float: /1In Lieu: OFFICE USE ONLY:Total Days Taken: Other:Flex:Vacation:Float:In Lieu:For:Conference: *Please inquire with Program Administrator if there are any questions about leave balances.      2319, 10240 Kingsway Avenue EDMONTON, AB T5H 3V9 Phone: 780-735-5954 Fax: 780-735-4969 % & ' ( 0 1 Y [ \ ] g h r s     ! 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