Leave Request Form
Today's Date
*
/
Day
/
Month
Year
Date
Is request leave less than 8 weeks away?
*
Yes
No
If yes, please give reasons below
Name
*
First Name
Last Name
Work email address
*
example@example.com
Position
*
Please Select
Nurse
CNS
Doctor
Consultant
Psychologist
Manager
*
Dr Gill McCarthy
Simon Green
Details of Leave
Leave Type
*
Annual leave
Study leave
Professional leave (meetings/exams)
Other
Other please state
Annual Leave
Annual leave left prior to this request (hours/PA's)
*
Is leave full day(s) or part day(s)?
*
Full day(s)
Part day(s)
Date of part day annual leave
/
Day
/
Month
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Total hours/PA's requested
*
First date of annual leave (first day of absence)
*
/
Day
/
Month
Year
Date
Last date of annual leave (last day before return to work)
*
/
Day
/
Month
Year
Date
Total hours/PA's requested
*
Clinics to be closed (you can select multiple)
NONE
Alpha
CPC
LARC
Consultant
Psychosexual
Detail of clinic closures
Include dates or affected clinics and any detail you think is of relevance
Study Leave
Is leave full day(s) or part day(s)?
*
Full day(s)
Part day(s)
Date of part day study leave
-
Day
-
Month
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
First date of study leave
*
-
Day
-
Month
Year
Date
Last date of study leave
*
-
Day
-
Month
Year
Date
Total hours requested
*
Total hours requested
*
Type of study leave
*
Please Select
Conference
Approved Course
Mandatory Training
Personal Study
Detail of type of study leave
*
Total study leave (hours) taken this year to date (April-April)
*
Clinics to be closed (you can select multiple)
NONE
Alpha
CPC
LARC
Consultant
Psychosexual
Detail of clinic closures
Include dates or affected clinics and any detail you think is of relevance
Enter the message as it's shown
*
Save
Request Leave
Clear Form
Should be Empty: