Leave Request Form

Name*
First Last
Email*
FMLA-Qualifying Event
- No
- Yes
For partial days, or a combination of leave types, please provide details in the additional comments below.
Type of Leave*
- Vacation
- Sick
- Other
Leave Begin Date*
MM slash DD slash YYYY
Begin Time*

: Hours

Minutes

AM/PM
Return-to-Work Date*
MM slash DD slash YYYY
Return-to-Work Time

: Hours

Minutes

AM/PM
Total Hours Requested*

Please round to the closest .25, .50, .75, or whole hour increment as appropriate.
Additional Comments

Florida’s Leading Academic Urology Program

Rated as High Performing Urology Program

Rated as High Performing in Prostate Cancer Surgery