REQUEST FOR LEAVE OF ABSENCE
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Faculty/Staff Member to return completed form to supervisor/department chair.
Title of Position:
LEAVE OF ABSENCE INFORMATION:
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:
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 and Medical Leave Act), Form WH-380-F ( ).
Indicate the nature and duration of the government service.
Attach OF69 Assignment Agreement. (Refer to SPG 201.30-5, Federal Personnel Agreements.)
Attach a copy of the Notice of Induction or Authorization for Active Duty.
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 ( ).
If receiving Workers’ Compensation, indicate whether you want to exhaust your vacation time before the leave begins.
Provide the date of the child’s birth. Date: ________________________ This leave is only applicable to employees
not eligible for extended sick time.
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.)
Leaves applicable to faculty members only:
Indicate the location and duties to be performed. (Refer to SPG 201.90, Duty Off-Campus.)
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.
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.)
Indicate specific plans and effective date of complete retirement. (Refer to SPG 201.81, Retirement Furlough.)
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.