Resident Travel Request Form

Name: (as it appears on photo ID)*

First NameLast Name

Name of Conference: *

Conference Location:

Conference Start Date:

MonthDayYear

Conference End Date:

MonthDayYear

Have you previously attended a conference within the current academic year? *

YesNo

If yes, did IM residency fund your travel? *

YesNo

Travel Details

If your travel is approved, hotel and flight accommodations will be made on your behalf. Please provide as many details as possible to aid in the booking of your travel. All airline accommodations will be sent to you for approval prior to booking.

Hotel Required?*

YesNo

Cost of Registration for conference: *

Outbound Flight Request

Departure Date (from LEX)*

MonthDayYear

Approximate Departure Time (from LEX)

:HourMinutesAM/PM Option

OR

Approximate Arrival Time at Conference Location

:HourMinutesAM/PM Option

Return Flight Request

Return Date (to LEX)*

MonthDayYear

Approximate Departure Time from Conference Location

:HourMinutesAM/PM Option

OR

Approximate Arrival Time (at LEX)

:HourMinutesAM/PM Option

Please provide any additional flight or travel preferences including airline rewards number, seat preference, and potential schedule conflicts. If you have a specific flight in mind you may list flight details here.

Traveling together? Please provide any roommate requests here.

Scholarly Activity

Please provide the details of your scholarly activity below. Be sure to log your activity in MedHub.

Are you presenting at this conference? *

YesNo

Scholarly Activity Type:

Name of presentation/abstract/research:

Coverage

Please note: You are personally responsible for arranging your own coverage while you are away at conference.

Have you arranged coverage prior to completing this form? *

YesNo

Total number of days requesting coverage:

What service are you on during the requested days off?

Who is the attending on service with you during the requested days off?

Please provide any additional details of your coverage (who/when).

Please upload your research acceptance notification here.

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