WVU :: School of Medicine :: Eastern Division :: Harpers Ferry Family Medicine

For Internal Use Only

Member:

FACULTY

RESIDENT

STAFF

NAME:

DATES REQUESTED OFF:
FROM: (First Day off)

TO: (Last Day Off)

Type of Leave:

	VACATION
	SICK
	CME
	OTHER
	Presentation of Officer at National/ State Association (Requires Chair approval for additional days)
	Meeting:
	Presentation Topic:
	Office Held:
	Location:
	Dates:
	(National - up to 5 additional days/year) (State - up to 2.5 additional days/year) TOTAL of 5 days per year
	COMMENTS:

Please note that all requests must be approved in writing by your Supervisor.

I understand that requests will be considered by my supervisor and in the event that my request is denied, I will be notified.