P.O. Box 100296
This letter is in reference to a mission trip I have planned to the LOCATION , --INSERT DATES-
. The primary purpose of this trip is
I request your approval of medical liability coverage for this trip through the UF Self-Insurance
Trust Fund as a community service activity. While participating in this endeavor, I will use
(please provide the type of leave that will be used ~administrative, annual, etc.) and forms
will be submitted for authorization.
Clinical and consultation coverage has been reassigned so that no interruption to patient
care should be experienced.
Thank you for your consideration of this request.
Department of Pediatrics
Title, Division of _________________
Supervisor, Title, Division of Pediatrics __________________
Richard L. Bucciarelli, M.D., Chairman, Department of Pediatrics
Michael L. Good, M.D., Dean, College of Medicine