SOM/cDHIP/DHIPFaculty & APP Leave of Absence (LOA) Intake Form

SOM/cDHIP/DHIP

Faculty & APP Leave of Absence (LOA)

Intake Form

Use this form if you are a SOM/cDHIP/DHIP faculty or APP initiating a LOA or Department Representative initiating a LOA request on behalf of a SOM/cDHIP/DHIP faculty or APP.

SOM/cDHIP/DHIP Leave of Absence (LOA) Process:

If the Department is initiating the LOA request, only upload the signed LOA Form. If an APP is initiating the LOA request, upload the signed LOA form and forms 1001, 1002E or 1002F, and 1003. If a Faculty member is uploading the LOA request, upload the signed LOA Form and supporting documentation based on your leave type.
Signatory pages must be signed by all parties and dated
Requests are routed to the SOM APT Office or DHIP Clinician Service Center to begin review and approval.
Requests for FML are routed to EOHW for initial determination before the SOM APT Office or DHIP Clinician Service Center will begin review.
Final determinations will be communicated as follows:

dFAC: the approval will be visible to the department representatives within 48 hours of approval.
Email: Directly to the faculty member or APP with copies sent to the department representative, SOM/APT Office, and other applicable parties. e.g., Employee Occupational Health and Wellness (EOHW).

Submitter Name*

Submitter Email*

Faculty Name*

Duke Entity Affiliation*

Select or enter value

Clinician Rank/Classification*

Select or enter value

Department*

Department Contact (name + email)*

Type of Leave (multi select)*

Select or enter value

dFac Attestation

Check this box to confirm that the signed LOA form has been successfully uploaded to dFac

File Upload*

In addition to uploading the fully executed DHIP/SOM LOA request form, you must also upload the following documents based on your selected leave type.

FML: Forms 1001, 1002-E(mployee) or F(amily) (Cert. of Health Provider), and 1003 (Notice of Eligibility). EOHW requires the department to provide an official FMLA tracking sheet with all FMLA requests to show any FMLA hours used within the last 12 months. If FMLA is not taken, a blank document will suffice. For a blank template, please email the DHIP Clinician Service Center or SOM APT Office at SOMAPT@duke.edu
TML: Form 1002-E (Cert. of Health Provider)
Parental: Form 1002-E(mployee) or 1002-F(amily) (Cert. of Health Provider)
Leave w/out pay: Letter to Dept. Chair describing circumstances for leave.
Sabbatical: Contact the SOM APT Office at SOMAPT@duke.edu
Military: Contact the DHIP Clinician Service Center or SOM APT Office at SOMAPT@duke.edu
Other: Contact the DHIP Clinician Service Center