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Return from Leave of Absence Request

(All fields as mandatory)

Name:
Email:
Area of Specialty:
Leave start date:	Date and timeNow
Return date:	Date and timeNow
CPD Obligations – please indicate yes or no
YesNo	I have satisfied the Continuing Professional Development requirements for continuing accreditation as an Accredited Specialist in accordance with the Specialisation Scheme Rules, for the period whilst on a Leave of Absence.
YesNo	I have retained a record of my Continuing Professional Development activities during this period in accordance with the Specialisation Scheme Rules, and I agree to submit evidence of my participation in these activities if requested to do so.
Substantial involvement in the area of practice – please indicate yes or no
YesNo	Upon return to practice, the time I will devote to this area of practice is at least 25 per cent of the time required to conduct a full-time practice.