ࡱ> LOKC bjbj 4@hh 8<.|b$V !^ТvtO20b$"$"$"$b$"X l: CONSULTANT AND SAS DOCTORS APPLICATION FOR PROFESSIONAL LEAVE This form should be submitted 6 weeks prior to the dates requested where possible, or as soon as notification of commitment is received, whichever is the earlier. Personal Details Name........................................ Speciality: ....................................... Reason for Professional Leave Please Specify.  Details of proposed absence Date From ...................................... To ..  Total number of missed working days: .................................................... OR Total number of missed fixed commitments: ..........................................  PAs Affected (Clinics/Theatres/Ward Rounds etc)  Date and time (AM/PM) PAs to be covered/cancelled or amended  Clinical Lead Informed Yes / No Emergency on-call cover provided (insert name).......................................................... . (Switchboard informed) Yes / No  Author: Dr Christine Blanshard MEDICAL DIRECTOR DATE OF NEXT REVIEW September 2018 Version: 2PROFESSIONAL LEAVE POLICY Signatures and Approvals Employees Signature I declare that the information I have given on this form is correct and complete. I understand that if I knowingly provide false information this may result in disciplinary action and I may be liable for prosecution and civil recovery proceedings. I consent to the disclosure of information on this form to and by the Trust and the 㴫ý Counter Fraud and Security Management Service for the purpose of verification and the investigation, prevention, detection and prosecution of fraud. Signature................................................ Date............................................... Please complete all sections of the form ensuring it has been signed by your rota master or Clinical Lead and Clinical Director before returning it to MD Signature of Clinical Lead: Cover Arrangements Are the emergency cover arrangements satisfactory? YES/NO Name of person(s) providing the cover: .................................................................. Job Title............................................ Department: .................................... Signed........................................................... Date ...................................  Signature of Clinical Director: Approved YES / NO If no provide reasons below Signature: ............................................. Date . Reasons why not approved ..  Medical Directors Signature: Approved YES/NO If no provide reasons below: Signature: ............................................. Date . Reasons why not approved ..  Author: Dr Christine Blanshard MEDICAL DIRECTOR DATE OF NEXT REVIEW: September 2018 Version: 2PROFESSIONAL LEAVE POLICY     APPENDIX A >?]e  . 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