GI Faculty Schedule Request Form GI Faculty Schedule Request Form Copy link "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Name * Required First Last Email * Required Managers NameEce MutluBrian BoulayJamie BerkesI would like to: * RequiredSubmit a New Request for LeaveChange an inpatient service block assignmentChange an on-call coverage assignmentCancel an Existing LeaveSubmit a New Request for LeaveLeave Start Date * Required MM slash DD slash YYYY Leave End Date * Required MM slash DD slash YYYY First Date Back To Work * Required MM slash DD slash YYYY Is this request less than 6 weeks out? * Required Yes No "This request is less than 6 weeks. Please provide the date(s) for your make-up clinic. After submitting this form, please also email or call your manager to notify them of your absence and request approval. Your request may not be accommodated if you fail to email or call your manager right away."Please select reason for absence Sick Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering Provider Please select reason for absence Vacation Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering Provider Please select reason for absence Bereavement Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering Provider Please select reason for absence Time off without pay Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderPlease select reason for absence Jury Duty Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering Provider FMLA Maternity/Paternity Leave Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering Provider FMLA Other Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering Provider Conference/CME/Work related Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderAdditional Information (Please indicate coverage information below if applicable)Change an inpatient service block assignmentWill your schedule request occur within the next 90 days? Yes No Service Type * Required Biliary Hepatology Gastroenterology Are you requesting a switch of an inpatient service block assignment? Yes No Name of individual you are switching with * Required First Last Email of individual you are switching with * Required Original Schedule Start Date * Required MM slash DD slash YYYY Original Schedule End Date * Required MM slash DD slash YYYY Proposed Schedule Start Date * Required MM slash DD slash YYYY Proposed Schedule End Date * Required MM slash DD slash YYYY Original Schedule Start Date * Required MM slash DD slash YYYY Original Schedule End Date * Required MM slash DD slash YYYY Additional InformationAdditional InformationChange an on-call coverage assignmentWill your schedule request occur within the next 90 days? Yes No Service Type * Required Biliary Hepatology Gastroenterology Are you requesting a switch of an on-call coverage assignment? Yes No Name of individual you are switching with * Required First Last Email of individual you are switching with * Required Original Schedule Start Date MM slash DD slash YYYY Original Schedule End Date MM slash DD slash YYYY Proposed Schedule Start Date MM slash DD slash YYYY Proposed Schedule End Date MM slash DD slash YYYY Original Schedule Start Date MM slash DD slash YYYY Original Schedule End Date MM slash DD slash YYYY Additional InformationAdditional InformationCancel an Existing LeaveService Type * Required Biliary Hepatology Gastroenterology EPIC Inbox Coverage Original Schedule Start Date MM slash DD slash YYYY Original Schedule End Date MM slash DD slash YYYY First Date Back to Work MM slash DD slash YYYY Name of individual covering for you * Required First Last Email of individual covering for you * Required Is this request less than 6 weeks out? * Required Yes No "This request is less than 6 weeks. Please provide the date(s) for your make-up clinic. After submitting this form, please also email or call your manager to notify them of your absence and request approval. Your request may not be accommodated if you fail to email or call your manager right away."Please select reason for absence Sick Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderPlease select reason for absence Vacation Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderPlease select reason for absence Bereavement Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderPlease select reason for absence Time Off Without Pay Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderPlease select reason for absence Jury Duty Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderPlease select reason for absence FMLA Maternity/Paternity Leave Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderPlease select reason for absence FMLA - Other Leave Start Date MM slash DD slash YYYY Leave End Date MM slash DD slash YYYY Name of Covering ProviderEmail of Covering ProviderUntitled Δ