NOTICE OF ABSENCE/CHANGE IN SCHEDULE
Notice of absence/change in schedule must be completed by all staff to facilitate patient care
NAME:
SITE:
PROVIDER SCHEDULE CHANGE FOR PATIENT APPOINTMENTS
CURRENT SCHEDULE: CHANGE TO:
PERMANENT CHANGE
TEMPORARY CHANGE DATES
ABSENCE
DATES I WILL BE ABSENT TOTAL WORK HOURS ABSENT DATE OF RETURN TO WORK PERSON PROVIDING CLINICAL AND/OR OTHER COVERAGE DURING MY ABSENCE: NAME: SIGNATURE OF PERSON ASSUMING COVERAGE CONTACT NUMBER:
LEAVE REIMBURSEMENT REQUEST
# VAC HRS EXPLANATION (IF “OTHER” IS INDICATED) # SICK/PER HRS # OTHER HRS_______
YOUR SIGNATURE: SUPERVISOR APPROVAL:
DATE: DATE:
You are responsible for obtaining your Supervisor’s approval, and you are responsible for sending your Notice to the Human Resources Department by interoffice mail at UPC Jefferson, 5th Floor or by fax to 313-993-3997.
Revised 3/06