Notice of Leave of Absence

Fields denoted by an asterisk (*) are required.

Only Leaves of Absence of greater than ONE WEEK in duration must be reported to the PGME Office.

This form must be completed by the Program Director or Program Administrator.
Trainee Name Trainee Name First Last
Current Training Level
Training Program
Start Date of Leave Start Date of Leave / MM / DD YYYY
Expected Date of Return Expected Date of Return / MM / DD YYYY
Type of Leave (choose one)
Additional Notes
Please attach the supporting documentation for this leave using the "Select Files" button below.

Attach Files
Please refer to the Residency Leaves of Absence Policy. A leave of absence is an approved interruption of training, and may be classified as: Pregnancy and Parental Leave, Medical/Sick Leave, Personal Emergency Leave, Compassionate Leave, Educational Leave, and others. The Residency Program Director must approve all leaves of absence. By submitting this form, you attest that your program has approved this interruption of training.

Residents who have taken a leave of absence of more than one four-week block during the training year will proceed to the next PGY Level only at the discretion of the Program Director and/or Residency Program Committee (RPC) or Competence Committee (CC).

Residents returning after medical leave (or a leave of more than 6 months) must provide a written medical certificate from their treating physician indicating the resident's capability and fitness to return to the program. Should a modified return to work or accommodation be required, the trainee must contact the Learner Experience Office at equity.wellness@schulich.uwo.ca
Program Director's Name

For Program Director's name, refer to the PGME list of residency training contact list.
Program Administrator's Email Address
Please upload a copy of the Program Director's Signature using the "Select Files" field or Draw or type their signature in the Signature Pad field:
Attach Program Director's Signature or PGME Associate Dean Signature

Attach Files
Draw your signature into the box below.

Draw or Type

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Full Name

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Notice of Leave of Absence

Notice of Leave of Absence

Only Leaves of Absence of greater than ONE WEEK in duration must be reported to the PGME Office. This form must be completed by the Program Director or Program Administrator.

Please upload a copy of the Program Director's Signature using the "Select Files" field or Draw or type their signature in the Signature Pad field:

Only Leaves of Absence of greater than ONE WEEK in duration must be reported to the PGME Office.

This form must be completed by the Program Director or Program Administrator.