Doctor's name * What is your assignment number? * Department * First date of leave or absence * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Day of return to work * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 What type of leave are you taking? * Annual Sick Training/Education/ Study Leave (TESL) Other If 'Other' selected, please indicate reason for leave Do you utilise the operating theatres? * No Yes Have you cancelled your Outpatients Clinic? * Yes No Who will see your Inpatients? * Who will take your Emergency calls? * Who will manage your teaching commitments during your absence? *
