ACGME Medical, Parental or Caregiver Leave Request Form

Form to be completed by Program Coordinator or Program Director.

In order to submit this form the program must upload:

A written plan that addresses successful completion of program and board eligibility for resident/fellow. See template for assistance.
The completed and signed UAMS COM GME Medical, Parental or Caregiver Leave form.

Leave Request Form

This field is for validation purposes and should be left unchanged.

Name of Person Filling Out Form(Required)

First Last

Email of Person Filling Out Form(Required)

Trainee Information

Trainee's Name(Required)

First Last

Trainee's E-mail(Required)

Please use UAMS email address.

Name of Trainee's Program(Required)

Trainee's PGY(Required)

Is Trainee a J-1 Visa Holder?(Required)

Yes

J-1 Visa Holder(Required)

If trainee is a J-1 visa holder, the program must contact UAMS Immigration to complete a Required Notification of a Leave of Absence form. (Please initial to acknowledge.)

Form available at https://www.ecfmg.org/evsp/notification-LOA.pdf

Leave Information

Type of Leave Requested(Required)

Medical: I have a serious health condition that prevents me from working

Parental: Maternity, Paternity, Adoption, Foster Care Placement

Caregiver: I am caring for a spouse, child, or parent with a serious health condition

Reason for Parental Leave Request(Required)

(Select the option that best describes your situation)

I am giving birth

My spouse or partner is giving birth

I am receiving a child through adoption or foster care placement

Please provide the full name of the family member for whom you are requesting leave.(Required)

(e.g., spouse, partner, child, or parent)

First Last

Relationship to Family Member(Required)

Family Member's Date of Birth(Required)

MM slash DD slash YYYY

Expected Due Date(Required)

MM slash DD slash YYYY

Expected Start Date of Requested Leave(Required)

What is the date of your expected first day of leave?

MM slash DD slash YYYY

Expected End Date of Requested Leave(Required)

What is the date of your expected last day of leave?

MM slash DD slash YYYY

Are you going to be taking time intermittently or for a continuous block of time?(Required)

Intermittently

Continuous Block of Time

Unsure

Please describe your anticipated leave schedule.(Required)

If you expect to take leave intermittently, include the specific dates or patterns (e.g., every Friday, alternating weeks, or certain appointments). If you’re unsure, share any known details or expected frequency to help us plan accordingly.

Is this resident/fellow scheduled for a rotation at the VA during the requested leave dates?(Required)

Yes

Do you have any additional comments or information that you need or would like to to provide?(Required)

Yes

Additional Comments(Required)

Documentation

Please upload the signed and completed UAMS COM Medical, Parental, or Caregiver Leave Request Form(Required)

Max. file size: 15 MB.

Please upload written plan for resident/fellow's successful completion of program.(Required)

Max. file size: 15 MB.

Program Director has discussed with Housestaff Office any changes to scheduling that would impact funding.(Required)

Yes, I have before this submission

No, but I will after this submission

Program Administration Information

Program Coordinator's Name(Required)

First Last

Program Coordinator's Email(Required)

Program Director's Name(Required)

First Last

Program Director's Email(Required)

Program Director's Consent(Required)

1) I approve this medical, parental, caregiver leave request;
2) I agree to track and record leave dates;
3) I agree to provide information to Housestaff Office in a timely manner;
4) I agree to counsel resident/fellow on the impact of leave on their training end dates as appropriate.

PD approved (A copy of this form will be emailed to the PD when checked)