Office of Graduate Medical Education LOA Input Form

Office of Graduate Medical Education LOA Input Form

University of Minnesota Medical School GME Leave of Absence Input Form.

This form is only for Resident and/or Fellows.

Please see the linked FAQ for assistance pertaining to this process

Today's Date*

Resident/Fellow Information

Resident/Fellow First Name*

Enter ONLY first name

Resident/Fellow Last Name*

Enter ONLY last name

Resident/Fellow Email*

Enter the full email

Resident/Fellow Emplid*

Department*

Select

Anesthesiology Programs*

Select

Dermatology Programs*

Select

Diagnostic Radiology Programs*

Select

Family Medicine & Community Health Programs*

Select

Laboratory Medicine and Pathology Programs*

Select

Medicine Programs*

Select

Medicine & Pediatrics Programs*

Select

Neurology Programs*

Select

Neurosurgery Programs*

Select

OB GYN & Women's Health Programs*

Select

Ophthalmology & Visual Neurosciences Programs*

Select

Orthopedic Surgery Programs*

Select

Otolaryngology, Head and Neck Surgery Programs*

Select

Pediatrics Programs*

Select

Psychiatry Programs*

Select

Radiation Oncology Programs*

Select

Rehabilitation Medicine Programs*

Select

Surgery Programs*

Select

Urology Programs*

Select

Is this person on a J-1 Visa*

Select

Has this resident/fellow taken a leave of absence in the past?*

If no, proceed with the form.

If yes, ensure board requirements are met.

Yes

Leave of Absence Specifics

What type of leave?*

Select

Estimated LOA Start Date*

Do you have an estimated end date of this leave?*

Select

Estimated LOA End Date*

Paid Time Away Dates

Enter a range of dates in mm/dd/yy - mm/dd/yy format

Days of PTO

Please note any holidays

Unpaid Dates

Enter a range of dates in mm/dd/yy - mm/dd/yy format

Days of Unpaid Leave

Enter in required rotation days, if the trainee is not working weekends you do not need to count weekends.

Paid Parental Dates*

Enter a range of dates in mm/dd/yy - mm/dd/yy format

Days of Paid Parental Leave*

Time Away Extends Dates

Enter a range of dates in mm/dd/yy - mm/dd/yy format

For MMCGME Block Schedule Time (CMS Funding)

PGYx*

New Advancement Date to PGY

Will this LOA extend training?*

Select

Insert the new graduation date*

Enter the last day of the training program

Updated Training Dates by PGY Level (RMS)

Enter the last day of the program for current academic year if it has extended.

LOA Stakeholders Contacts

An individual with a M Physicians or other non-UMN email will not receive an alert.

If someone who does not have a x500 needs to be notified of this leave, you must manually forward the leave specifics to them.

Program LOA Contact Name*

Enter first and last name

Program LOA Contact Email*

Enter a personal work email. There is an option below to add a department email.

Check the box to add a Departmental Education email

Departmental Education Email*

Please message Christy Illig if an email is missing.

Select

Department HR Contact Name*

Enter first and last name

Department HR Contact Email*

Enter a personal work email. There is an option below to add a department email.

Check the box to add a Departmental HR email

Departmental HR Email*

Please message Christy Illig if an email is missing.

Select

Program Coordinator Contact Name*

Enter first and last name

Program Coordinator Email*

Enter the individuals full personal email.

Additional Information

Notes

Extra notes if applicable

Send me a copy of my responses

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