BUMG Faculty PTO Form

Hidden

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

Your Name(Required)

First Last

Your Email Address(Required)

How many groups of consecutive days off are you reporting?(Required)

Please enter a number from 1 to 5.

Start Date of PTO(Required)

End Date of PTO(Required)

Please identify whether the time off is vacation or sick days.(Required)

If you are reporting previous or anticipated leaves that do not fall in either domain, please notify the section administration at IDAdmin@bmc.org.

Are you an outpatient provider?(Required)

Who will be providing clinic coverage?(Required)

Please provide the provider's name covering your clinic.(Required)

Second Group of Consecutive Days Off

Start Date of PTO(Required)

End Date of PTO(Required)

Please identify whether the time off is vacation or sick days.(Required)

If you are reporting previous or anticipated leaves that do not fall in either domain, please notify the section administration at IDAdmin@bmc.org.

Are you an outpatient provider?(Required)

Who will be providing clinic coverage?(Required)

Please provide the provider's name covering your clinic.(Required)

Third Group of Consecutive Days Off

Start Date of PTO(Required)

End Date of PTO(Required)

Please identify whether the time off is vacation or sick days.(Required)

If you are reporting previous or anticipated leaves that do not fall in either domain, please notify the section administration at IDAdmin@bmc.org.

Are you an outpatient provider?(Required)

Who will be providing clinic coverage?(Required)

Please provide the provider's name covering your clinic.(Required)

Fourth Group of Consecutive Days Off

Start Date of PTO(Required)

End Date of PTO(Required)

Please identify whether the time off is vacation or sick days.(Required)

If you are reporting previous or anticipated leaves that do not fall in either domain, please notify the section administration at IDAdmin@bmc.org.

Are you an outpatient provider?(Required)

Who will be providing clinic coverage?(Required)

Please provide the provider's name covering your clinic.(Required)

Fifth Group of Consecutive Days Off

Start Date of PTO(Required)

End Date of PTO(Required)

Please identify whether the time off is vacation or sick days.(Required)

If you are reporting previous or anticipated leaves that do not fall in either domain, please notify the section administration at IDAdmin@bmc.org.

Are you an outpatient provider?(Required)

Who will be providing clinic coverage?(Required)

Please provide the provider's name covering your clinic.(Required)

Would you like to be sent your PTO summary after this submission is recorded?(Required)

Additional Comments/Questions

M	T	W	T	F	S	S
			1	2	3	4
5	6	7	8	9	10	11
12	13	14	15	16	17	18
19	20	21	22	23	24	25
26	27	28	29	30	31

PTO Notification Form

Next Steps: Sync an Email Add-On

Second Group of Consecutive Days Off

Third Group of Consecutive Days Off

Fourth Group of Consecutive Days Off

Fifth Group of Consecutive Days Off