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The Resident/Fellow Leave Form is used to submit a request for leave due to the Resident or Fellow's own medical condition, new parental responsibilities, or due to an immediate family member's medical condition. Leave is provided through University-approved policies/procedures and also in compliance with the ACGME.

This form must be submitted by the WVU Resident or Fellow who is requesting the leave. Please note that completion of this form initiates the leave request and should not be considered approval of the request.

Resident/Fellow - Please provide your information below:

Resident/Fellow's Full Name:

WVU Email Address:

Personal Email Address

Employee Number:

Home Phone #:

Work Phone #:

Resident/Fellow - Please provide your Program Manager's information below. An email will be sent to them notifying them of this request.

Program Manager's Name:

Program Manager's Email Address:

Please select the type of Leave being requested:

Medical (own medical condition)
Medical (pregnancy or childbirth)
Parental (non-birth parent, bonding with newborn or placement of a child with the employee for adoption with no medical complications present)
Caregiver (providing care for immediate family member)