Leave Of Absence Form - Neomed
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1
2Leave of Absence Form
Students who wish to take a leave of absence must petition to the Phase 2 Committee on Academic and Professional
Progress (CAPP) by completing the Leave of Absence Request form. The form, supporting documentation, and the student’s
entire academic record will be reviewed by CAPP. Leave of Absence Request Form and supporting documentation must be
returned to the Chief Student Affairs Officer in B-204, Student Affairs office.
Student Name:
College:
Medicine
Pharmacy
Class of
o
o
Leave of Absence Classification (check one):
Personal Hardship – Experience an unexpected crisis (including a crisis of a family member) that impacts a student’s
o
ability to participate in the curriculum.
Enrichment – Time away from the curriculum to pursue professional growth opportunity (e.g. field outside of
o
current program); student must be in good academic standing.
Leave of Absence Timeframe:
Proposed Start Date _______________
Expected End Date ___________________
Summary of Request:
(please use separate sheet if additional space is needed)
Deadlines:
Personal Hardship: deadline is open; as the hardship arises
Enrichment: February 1 for consideration of next academic year
Documentation:
Personal Hardship (unless financial hardship) Documentation must include, but is not limited to:
•
Letter from healthcare professional, excluding a family member or NEOMED’s personal advisor to attest
to condition/situation of student or family member
Enrichment Documentation must include, but is not limited to:
•
Outline of enrichment activities that includes supervisor’s contact information, goals/objectives of
responsibilities, anticipated dates of completion
•
Statement by supervisor approving activities
•
Explanation for how activities will improve student’s professional success
•
If pursuing another degree program at NEOMED, an acceptance letter from the College should be remitted in place
of the items outlined above.
I certify that the information presented here is accurate. I understand that any misrepresentation of facts on this form could
result in denial of my request or dismissal from the Northeast Ohio Medical University.
_____________________________________________
__________
Student Signature:
Date:
FOR ADMINISTRATIVE USE ONLY:
___________________________________
_______________________
o Approved
o Not Approved
NEOMED Signature
Date
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