Department of Orthopaedic Surgery Residency Program • Time Away Form PGY2-5
- Use one form for each set of dates Date of request:
NAME OF RESIDENT
DATES REQUESTED
First day away:
PGY-
Last day away:
SITE AFFECTED
TYPE OF TIME AWAY REQUEST
Personal Time Off (PTO)
Vacation
Fellowship Interview
Non-department sponsored trip (list)
GCSH
RGHP
HCMC
VAMC
UMMC
TRIA
List UMMC/TRIA Rotation:
Department-Sponsored *
Podium Presentation:
Resident Representative:
Other:
 attach copy of notification acceptance (abstract, AOA/AAOS
representative, international travel)
Other
Parental
Jury Duty
Court
Other List:
Note: Notice of Parental Leave requires 4-week advance notification. See Institutional Policy manual at http://www.med.umn.edu/gme/residents/home.html
How will patient care and call coverage be arranged while you are gone?
- PLEASE SUBMIT FORM TO BETSY
Rest of form to be completed by Site/Rotation Directors
Approved
WEHRWEIN -
OFFICE USE ONLY
ENTERED ON SITE
CALENDAR
Denied and reason:
SENT FAX OR EMAILS:
SITE/ROTATION DIRECTOR SIGNATURE
DATE
OTHER SITE/ROTATION DIRECTOR SIGNATURE
DATE
SUPPORT STAFF
NOTIFIED WHEN
APPROVED
PROGRAM COORDINATOR
HAS RECORDED FOR
COMPLIANCE
PROGRAM DIRECTOR SIGNATURE
DATE
Required for: department-sponsored trip • when gone longer than one week
EMAIL/FAX THIS FORM WHEN COMPLETED TO BETSY WEHRWEIN AT wehrw005@umn.edu (612) 273-8099
2012-2013 Academic Year
ORSU – June 2012
Personal Time Off PGY2-5
The following number of personal days have been allocated for 2012-2013.
PGY-1
PGY-2
PGY-3
PGY-4
15
Days/year
15
15
15
PGY-5
15
Personal time off includes vacation, job and fellowship interviews (see below), and non-department sponsored
courses (e.g. review courses). It is based on a five-day work week, with call coverage on adjacent weekends to
be arranged by the resident. Unused personal time off cannot be rolled over into next academic year.
A Time Away form must be signed by the affected site/rotation director(s). In addition, while on UMMC
Orthopaedic Surgery rotations, all faculty affected by the absence of the resident must be notified of the
requested time away and documented on their respective calendar.
No service or rotation can deny a request provided that no more than one resident is away from the site and
patient care responsibility and call coverage are properly arranged. Any exception to this will require written
approval by the program director.
No more than one week of personal time off may be taken at a time, except under extreme circumstances and
must be pre-authorized by the program director.
Personal time off requests will be accommodated on a first-come, first-served basis.
Personal time off may not be taken when the resident’s absence would require another resident to take call more
than every third night in a hospital.
Personal time off will be taken for the first five days a resident is away from the rotation due to
fellowship interviews. Subsequent days taken will be department-sponsored.
No time off is granted during the last week of the academic year.
The department program is responsible for monitoring all time off, regardless of site or rotation. Sites may have
their own particular requirements as well. Permission granted from a particular site or rotation must be directed
to the program education coordinator to monitor compliance. Any violation will be notified immediately.
See also Travel Policy.
Gillette
Time Away forms are signed by Deborah Quanbeck, M.D.
Hennepin County Medical Center
Time Away forms are signed by Thomas Varecka, M.D.
Regions Hospital
Time Away forms are submitted no less than six weeks in advance to the dates requested to Thuan Ly, M.D. for
approval. Once approved, time away is put on the calendar and paperwork is sent to the University of
Minnesota for documentation purposes.
University of Minnesota Medical Center / TRIA Orthopaedic Center
A Time Away form is submitted to the program education coordinator no less than six weeks in advance of dates
requested, with the exception of fellowship interviews. All faculty affected by absence will be notified. The
rotation director must approve time away.
Veterans Affairs Medical Center
Time Away forms are signed by Terence Gioe, M.D.
2012-2013 Academic Year