Fillable 1) Use this form to request any leave (Texas Tech University-Health Sciences Center)

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1) Use this form to request any leave (Texas Tech University-Health Sciences Center)

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PLEASE READ:
1) Use this form to request any leave for the residency year 2020-2021.
2) Please complete all fields. If no current teaching or precepting activities, please state “none”.
2) Please obtain signatures from both your preceptor AND from your program director for the period of absence.
3) Email this form to Iverlyn Peng at Iverlyn.peng@ttuhsc.edu no later than 1 week before your leave (vacation or professional
leave) or 1 week after your return from sick leave. You will receive e-mail notification of receipt.
4) All requested leave is subject to prior approval from the Program Director and Vice Chair for Residency Programs. Failure to
complete all fields/signatures and submit within the requested time frame may result in an automatic denial of request.
5) You and your Program Director will receive a summary leave report via email.
6) If you have questions about or want to know your leave balance, please contact Iverlyn Peng at the above email address.
Resident Name: Date of Request:
Campus: ☐ Abilene ☐ Amarillo ☐ Dallas ☐ Lubbock
Type of Leave:
☐ Vacation
☐ Sick Leave
☐ Professional Leave. (Please specify): _____________________________________
☐ Interview Leave. (Please specify): _____________________________________
☐ Other Leave. (Please specify): ___________________________________
Beginning
Date of
Absence:
End
Date of
Absence:
Total Days
Requested:
Teaching Activities scheduled during leave:
Teaching Activities will be covered by:
Has the covering person been notified and agreed to such responsibility? ☐ Yes ☐ No
Practice Site Activities will be covered by:
Current Preceptor Name:
Preceptor Signature: __________________________ Date:
Residency Program Director Name:
Program Director Signature: ______________________ Date:
To Be Completed By Office of Residency Programs
Vice Chair of Residency Programs Signature: __________________ Date: ___/____/___
TTUHSC Resident Vacation, Sick, & Professional Leave Form
Email: iverlyn.peng@ttuhsc.edu
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Updated: 6/10/2020
INSTRUCTIONS
For FIRST-YEAR (as TTUHSC employee) TTUHSC-funded residents:
PGY1 Community (Dallas)
PGY1 Pharmacotherapy (Amarillo & Lubbock)
PGY1 Pharmacy (Presbyterian & Harris Methodist)
PGY2 Ambulatory Care (Amarillo)
PGY2 Geriatrics (Dallas)
PGY2 Oncology (Dallas)
If Submitting for Vacation Leave:
If during the time frame of July 1
st
, 2020 to December 31
st
, 2020 the resident must:
Submit a TTUHSC Resident Vacation, Sick, & Professional Leave Form;
OR
If during the time frame of January 1
st
, 2021 to July 2
nd
, 2021 the resident must:
Submit a TTUHSC Resident Vacation, Sick, & Professional Leave Form AND
Complete the “TTUHSC Exempt Employee Leave Report” for the appropriate month for all
vacation leave within WebRaider*
no later than the 15
th
of the following month.
If Submitting for Sick Leave:
Submit a TTUHSC Resident Vacation, Sick, & Professional Leave Form AND
Complete the “TTUHSC Exempt Employee Leave Report” for the appropriate month for all sick
leave within WebRaider*
no later than the 15
th
of the following month.
If Submitting for Professional Leave:
All residents must submit a TTUHSC Resident Vacation, Sick, & Professional Leave Form (ONLY).
For SECOND-YEAR (as TTUHSC employee) TTUHSC funded residents:
PGY2 Pharmacotherapy (Amarillo & Lubbock)
If Submitting for Vacation and/or Sick Leave:
Submit a TTUHSC Resident Vacation, Sick, & Professional Leave Form AND
Complete the “TTUHSC Exempt Employee Leave Report” for the appropriate month for all
vacation and/or sick leave within WebRaider*
no later than the 15
th
of the following month.
If Submitting for Professional Leave:
All residents must submit a TTUHSC Resident Vacation, Sick, & Professional Leave Form (ONLY).
NOTES:
*WebRaider instructions will be sent to you via email.
For Other Leave, please contact your local HR office or Iverlyn Peng
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1) Use this form to request any leave (Texas Tech University-Health Sciences Center)

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Completed 24 July 2020

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