Requestor Name: Click here to enter text.	Date: Click here to enter a date.

Absence Request Form

Faculty/Physician/Staff

THIS FORM SHOULD BE SUBMITTED BEFORE COMPLETING TRAVELWAYNE

Instructions: Requests for time off are granted based on staffing, availability of accrual time, and the operational needs of the unit (unless a personal or family emergency is involved). At least 60 days is required advance notice for Clinical/Precepting duties. When planning for a personal or business related absence:

confirm your own time availability and remember to log time off in appropriate time tracking system (WSU Academica web-entry or Workday if Wayne Health (WH) is primary employer or your position is percentage paid between WSU and WH log in both).

business travel requests, attach registration info, program agenda or speaking engagement invitation, etc. WSU faculty/staff REMINDER: in your TravelWayne pre-trip request you must upload registration info/agenda and approved absence documentation with all travel requests.

complete all parts of this form

send this form via email or hardcopy to your Immediate Supervisor to obtain approval with Cc to Judith Magdalenic as designated by Department Administrator (Andy) who has the responsibility to monitor time off requests. NOTE: Remember for business travel requests, you must upload this approved documentation in TravelWayne.

WH physicians, process time off request through Workday, send notice of approval to Judy upon receipt. Andy will notify Clinical Admin. to close schedule. NOTE: 60-day notice is required for clinic closure. If requesting CME reimbursement, travel expenditures must be approved in advance via email by Andy prior to requesting time off.

Upon receipt of the original or a pdf copy of the approved absence request, Judy Magdalenic will log time on the departmental Outlook calendar.

Type of Time-Off Request	First Date Off	Indicate Full/AM/PM	Last Date Off	Indicate Full/AM/PM	Date Returning To Work	# of Work Days Out of the Office
Vacation	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
Personal	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
Any purpose	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
Illness	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
Floating Holiday	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
PTO (WH only)	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
Business Travel* (attach info)	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
CME* (attach info)	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
Prof. Devel.* (attach info)	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
Bereavement	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
Jury Duty	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
FMLA (must have advanced HR approval)	Click here to enter a date.	Choose an item.	Click here to enter a date.	Choose an item.	Click here to enter a date.	Click here to enter text.
*Brief description of travel, CME or Professional Development Activity (attach registration info, program, details, speaking engagement invitation, meeting agenda, etc.): Include conference name and location (city/state): Click here to enter text.
Immediate Supervisor/Manager Signature (or email approval will be included with filed documentation)	Approved☐	Denied☐	Click here to enter a date.

If Applicable: Logged in NI ☐ Updated Time-Off Log ☐ Entered in IDX/PerfectServe ☐ Email to Faculty ☐

Sent to Judy Magdalenic ☐ Added to Department Calendar & Filed ☐