Application for Leave - DOC by dfhrf555fcg


Application for Leave

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									                               Medical and Dental Staff
Procedure for Application of Annual Leave and Study Leave
   Applications for study Leave must be made at least 6 weeks before dates requested.
         Retrospective forms will not be considered for funding external courses.

Doctor / Dentist responsibilities

1. Complete and Sign relevant section of Application Form
   Page 1 for Annual Leave / Page1 - 3 for Study Leave

2. Identify arrangements for clinic and on-call cover

3. Forward to Clinical Lead for approval

Clinical Lead responsibilities

4. Ensure adequate cover for duties / clinics / on-call

5. Ensure study leave meets the following criteria:

      Provides value for money
      Is clearly linked to organisational and service priorities and objectives
      Is identified as necessary/mandatory for the role and recorded in the personal development plan
      Is identified as necessary/mandatory for the service and recorded in the service/team learning &
       development plans
      Is equally accessible to relevant staff across the organisation

6. Forward completed forms to Assistant Director

Assistant Director Responsibilities

7. Review the application for Annual Leave / Study Leave

8. Ensure Study leave meets the above criteria

9. Forward forms to Human Resources or Learning and Development for action, recording
   and filing

Please note:

Human Resources and Learning and Development will collect, collate and
record leave information and forward reports of such to Clinical Lead and
Assistant Director.
                                Medical and Dental Staff
                     Application for Annual Leave and Study Leave
Title             Mr          Mrs         Miss         Ms                Dr       Dentist           Other

Forename                                                    Surname

Job Title                                                   Base

Department                                                  Division

Address                                                     E-mail Address

                                                            Telephone No

Post Code                                                   Mobile No

Mandatory Training up to date                               Yes          No
Managers Name                                               Signature
Name                                                        Signature

I wish to apply for             days   Annual Leave         Study Leave           Please circle

From:                                            To:                              Both dates inclusive

Leave type                          Annual Leave                          Study Leave
Leave entitlement                                   Days                                     Days

Leave already taken                                 Days                                     Days

Leave Remaining                                     Days                                     Days

Date returning to duty:

What Arrangements have been made to cover duties / clinics / on- call during your leave

Signed                                                            Date

Agreed by Clinical Lead:                                                                (Signature)

        (If study leave also sign on page 4)

Noted by Assistant Director ………………………………… (Signature) to forward

Annual Leave to : Human Resources                Study leave to: Learning and Development
                  Huntingdon House                                       Pikes Lane Centre

                                                 Page 1 of 3
                                   Funding request for external training:
                                    Application and Statement of case
         APPLYING FOR:
Course Title


Duration                                              Start                       End Date

Study leave with pay                                          Yes          No

Course/tuition fee                           £                Office Use
If fees are more than £1000, the                              Amount of funding previously used:
course needs to be agreed and                                 £
signed for by the Medical Director
(Page 3)
Examination fee                              £

Other expenses                               £                Budget Code for
Budget Code for:
Travel / Other Expenses
Note economy rail/air travel will be
covered, or car mileage at
Subsistence rate:

Statement of Case:
Which organisational/directorate priorities does the training link to?
Note: if this information is stated in the PDP then you don’t need to duplicate it – just refer to the section in the PDP

Which personal/team objectives does this training link to?
Note: if this information is stated in the PDP then you don’t need to duplicate it – just refer to the section in the PDP

Is the training necessary for revalidation/re-registration?
Yes        No
If yes please give brief details

                                                              Page 2 of 3
How will the learning be disseminated/cascaded/used on return to the workplace?

If the training is a necessary part of a role/service redesign or development, please provide brief details:

What are the risks of not funding this training?

Any further information you wish to supply

Medical and Dental staff MUST have the agreement of their clinical lead and Assistant Director
1) Assistant Director or                                                                Date
  Head of Clinical Services
  (name & signature)

2) Medical clinical Lead                                                                Date
  (name & signature)

3) Medical Director                                                                     Date
   (if required)

Approved by Director of Primary Care Provision                                          Date
     Anna Basford                   Signature

Learning and Development                                                                Date

                                                        Page 3 of 3

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