David Geffen School of Medicine at UCLA
LEAVE OF ABSENCE REQUEST FORM
A student may be granted a leave of absence (LOA) of one year with possible extension for one additional year.
All leaves will be for a specified period of time and must be approved by the Associate Dean for Student Affairs.
For medical leave - please use Medical Leave of Absence Request (MLOA)
First & Last Name (printed clearly): ______________________________________
Current Telephone #: _______________________________
Return completed LOA form and supporting documentation (i.e. copy of research/program acceptance letter) to the Registrar via email at
email@example.com, fax (310) 794-9574 or in person (12-159 CHS; M-F 8:00am – 5:00pm);
If you receive financial aid it is strongly advised you visit the
Financial Aid & Scholarship
website to learn how your leave affects your current
financial aid eligibility. It is your responsibility to familiarize yourself with the Leave of Absence & Withdrawals & SAP Policies;
Update your contact information (current mailing address and phone number) at MyUCLA;
I understand that should I not fulfill my USMLE requirements, as applicable, my request for a leave is null and void and will result in the
changing of my leave to an Administrative Leave.
Requested leave date (Month, Day & Year): __________________
Anticipated return date (Month & Year):_________________
Personal (Family Emergency)
Pursuit of another degree
(i.e. Ph.D., J.D., MBA, MPH, etc.)
I have considered all academic and financial ramifications of my request, effective on the date I have requested.
Student Signature: _______________________________________
Office use only
Hold – Pending the following: ____________________________________________________________________________________
Lee Miller, M.D. , Associate Dean or Meredith Szumski, Ed.D.
Leave Category: MSTP
MD/MBA (Concurrent Degree)
MD/MPH (Concurrent Degree)
MD/MPP (Concurrent Degree)
Effective leave start date:
Expected return date:
Return as a:
Dual Degree _____ Enrollment Status _____ Expected Grad Date _____
Start Date-Memoranda _____
Change of Status Entry _____
ListServs _____ SRS __ __
SOM/Housing Notification _____
FAO Notification _____
Main Campus ______
Academic/Clinical Files ____