Sick Leave Request Form | UAMS Department of Physical Medicine and Rehabilitation

Once this form is submitted, a copy will be emailed to the Program Director and Program Coordinator. Sick leave requested for medical appointments MUST be requested in advance using the Sick Leave Request Form. If sick leave is requested for medical reasons that do not allow advance notice the Resident must:

Contact the Chief Resident/s by phone or pager– Chief Resident/s will assign coverage, if necessary.
Contact the assigned PM&R attending faculty member by phone or pager (i.e., ACH, BHRI, UAMS, VA).
Notify the Residency Program Director by phone.
Notify the Residency Coordinator by phone.

Name * Required
I have contacted the Chief Resident/s, Attending Faculty, Program Director and Program Coordinator to let them know I will be taking sick leave. * Required
- Yes
- No
Date Requesting Sick Leave * Required
MM slash DD slash YYYY
Date to Return to Work * Required
MM slash DD slash YYYY
Reason for Sick Leave Request * Required