Form 36609 - Request For Leave Of Absence

Download a blank fillable Form 36609 - Request For Leave Of Absence in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 36609 - Request For Leave Of Absence with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.


Page 1 of 2
Faculty/Staff Member to return completed form to supervisor/department chair.
Last Name:
First Name:
Middle Name:
Title of Position:
Department Address:
Date of Request:
Supervisor’s/Department Chair’s Name:
Supervisor’s/Department Chair’s Signature:
Check the type of leave, supply the required information in writing, and provide attachments as indicated.
Reference Standard Practice Guide 201.30 and 201.30-1, Leaves of Absence. NOTE: Faculty and Staff represented by a Union should refer to
the collective bargaining agreement that governs the terms and conditions of their employment for information regarding leaves of absence.
Leaves applicable to faculty and staff:
Child Care
State the date of the child’s birth, adoption, or foster placement. Date: __________________________
Indicate school and credit hours. If not a UM student, attach a completed Educational Leave of Absence Addendum,
available at , to verify registration.
Attach U.S. Department of Labor Certification of Health Care Provider For Family Member’s Serious Health Condition
Family Care
(Family and Medical Leave Act), Form WH-380-F ( ).
Government Service
Indicate the nature and duration of the government service.
Attach OF69 Assignment Agreement. (Refer to SPG 201.30-5, Federal Personnel Agreements.)
Personnel Assignment
Military Service
Attach a copy of the Notice of Induction or Authorization for Active Duty.
Qualifying Exigency
Attach a copy of the U.S. Department of Labor Certification of Qualifying Exigency For Military Family Leave (Family and
Medical Leave Act), Form WH-384 ( ).
Attach a copy of the U.S. Department of Labor Certification for Serious Injury or Illness of Covered Servicemember -
Care of a Covered
for Military Family Leave (Family and Medical Leave Act), Form WH-385 ( ).
Personal Medical
If receiving Workers’ Compensation, indicate whether you want to exhaust your vacation time before the leave begins.
Medical/Child Care
Provide the date of the child’s birth. Date: ________________________ This leave is only applicable to employees
not eligible for extended sick time.
Phased Retirement
Use this form to initiate a phased retirement program. Describe the arrangement for the phased retirement program.
(Refer to SPG 201.83, Retirement.)
State the reason for requesting the leave: ___________________________________________________________
Use this form to establish the initial seasonal leave period. (Refer to SPG 201.30-3, Seasonal Leave of Absence Appointment.)
Seasonal Leave
Leaves applicable to faculty members only:
Indicate the location and duties to be performed. (Refer to SPG 201.90, Duty Off-Campus.)
Duty Off-Campus
Outside Teaching
Indicate the name of the educational institution and the duties to be performed.
State the nature of the research program, the location, and the funding source.
Phased Retirement
Indicate specific plans and effective date of combined retirement furlough and phased retirement plans. (Refer
to SPG 201.81, Retirement Furlough and SPG 201.83, Retirement.)
Retirement Furlough
Indicate specific plans and effective date of complete retirement. (Refer to SPG 201.81, Retirement Furlough.)
Scholarly Activity
State the nature of the activity, the location, and the funding source. (Refer to SPG 201.30-4, Scholarly Activity Leave.)
I request that my leave begin on __________________________ and end on ___________________________. (If necessary, give approximate dates.)
I understand that returning to work before the leave’s expiration date is at the discretion of the University. NOTE: Assuming that I have an eligible
appointment upon my return from leave, I authorize the University to automatically re-enroll me (and my dependents, if applicable) in those Benefits
Plans in which I was enrolled as of my last day of work (prior to the leave) and to deduct any resulting costs from my earnings. My most recent benefi-
ciary designation for Group Life insurance will be continued.
Office Phone:
Faculty/Staff Signature:
Home Phone:
Home Address:
Form 36609
Revised 11/10
Available at:


00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Page of 2