Faculty members are required to notify their departments in advance of absences that will take them away from their “classes or other regular duties at the University. Faculty Policies and Procedures requires that prior permission be received from the chancellor or the dean. The Medical School Dean has delegated the responsibility for approval of absences to the departmental Chairs. For purposes of accountability to the University and the State, it is important that all faculty members file the following form with the department Chair in advance of foreseeable absences. Needless to say, absences caused by illness or mishap can only be reported retrospectively. If you intend to use colleague coverage during an absence, please specify the educational duties that will be covered by your colleague.

Please give this form to the department Chair at least 10 working days prior to your anticipated absence. The Chair will respond within 5 days if the absence is not approved.

Dates of anticipated absence:

Leaving: __________________________ am pm(circle one)

Back in office:__________________________ am pm (circle one)

Reason for absence:

___ Vacation - how many days will be counted as vacation? _____ # of days

___ Colleague Coverage (requires prior approval unless you are ill) ___# of days

___ Professional activity (present seminar, attend professional meeting, study section, etc.)

___ Outside activity related to university duties (e.g., consulting) - _____ # of days

Where can you be reached while you are away?

Location (be specific): ________________________________________________________________________________________________________________________________________

Phone number: ______________________ Fax (if available): ______________________

While you are away, who will cover your teaching, research and administrative duties (circle)?

Bertics - 2-8667	Fillingame - 2-1439	Keck - 3-1815
Brow - 2-1475	Fox - 2-9370	Kiley - 2-6632
Dahlberg - 2-1459	Hull - 5-5441	Sheets - 2-9452
Denu - 5-1859	Kahan - 3-1864

Name (printed): ____________________ Signature: _________________ Date: ______

Chair’s signature (approval): ____________________________________ Date: ______