Request Form For Leave Of Absence Without Pay
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1
2REQUEST FOR LEAVE OF ABSENCE WITHOUT PAY
(For faculty only – Please see following page for definitions and guidelines)
June 2013
TO BE COMPLETED BY FACULTY MEMBER
Name: ________________________________________________________ Rank: ___________________
School/Department/Unit: __________________________________________________________________
Check one:
Tenured
Tenure Track
, Current probationary year, circle one:
1
2
3
4
5
6
Do you wish to request to extend your probationary period for one year?
Yes
No
(If yes, submit the Request to Extend the Probationary Period form found on the Faculty Affairs web site)
Temporary
Check one:
New Request
Extension of Current Leave
Check one:
Full
Partial, percent of time base requested as leave: ________________________________
Check one:
Academic Year (
)
Fall (
)
Spring (
)
Other, from ________ to _________
year
year
year
date
date
Check one: Request for Personal Leave without Pay
Request for Professional Leave without Pay
Maternity/Paternity
Research
Unpaid sick leave
Advanced study
Family care leave
Professional development
Outside employment
Other
Other
Additional information about purpose of leave (Attach additional page if necessary or preferred):
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Faculty Signature: _______________________________________________________ Date: __________________
N.B. Please contact the Human Resource Benefits Division to obtain information about the financial impact of
continuing benefits while on leave without pay. All signatures below are required in order to process your request.
TO BE COMPLETED BY DEPARTMENT CHAIR/UNIT DIRECTOR
Recommend Approval: Yes No
Comments:
Signature: _____________________________________________________________ Date: ____________________
TO BE COMPLETED BY COLLEGE DEAN/UNIVERSITY LIBRARIAN/ADMINISTRATOR
Recommend Approval: Yes No
Comments:
Signature: _____________________________________________________________ Date: ____________________
TO BE COMPLETED BY DEAN OF FACULTY AFFAIRS & PROFESSIONAL DEVELOPMENT
Recommend Approval: Yes No
Comments:
Signature: ______________________________________________________________ Date: ___________________
TO BE COMPLETED BY UNIVERSITY PROVOST, ACADEMIC AFFAIRS
Yes No
Approved:
Comments:
Signature: ______________________________________________________________ Date: ___________________
TO BE COMPLETED BY ASSOCIATE VICE PRESIDENT OF HUMAN RESOURCES
Yes No
Approved:
Comments:
Signature: ______________________________________________________________ Date: ___________________
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