Extended Leave Request Form
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David Geffen School of Medicine at UCLA
REQUEST TO EXTEND LEAVE
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.
*Although MSTP student leaves are approved for greater than one year the Request to Extend Leave Form must still be completed
First & Last Name (printed clearly): ______________________________________
UID: ____________________________
Current telephone #: _________________________________
Program Affiliation:
DREW/UCLA
UCLA
UCR/UCLA
UCLA/MSTP
DDS
DREW/PRIME
UCLA/PRIME
UCR/PRIME
Will return as a:
1
Year
2
Year
3
Year
4
Year
st
nd
rd
th
Anticipated return date (
Month & Year):____________________
Student Signature: _______________________________________
Date: _________________
Option A
Instructions for Requesting Extension of Original Leave
Submit completed Request to Extend Leave Form, AND reason for extension in space provided below, to the Registrar, via
next academic year
email (registrar@mednet.ucla.edu) or fax at (310) 794-9574 in the month of
October prior to the
(i.e. your extension request is for the 2017-2018 academic year then the form must be submitted in January 2016).
Reason for extension? __________________________________________________________________________________
Option B
Instructions for Requesting Extension of Leave for Other Reasons
Submit completed Request to Extend Leave Form, AND reason for extension in space provided below, to the Registrar, via
next academic year
email (registrar@mednet.ucla.edu) or fax at (310) 794-9574 in the month of
October prior to the
(i.e. your extension request is for the 2017-2018 academic year then the form must be submitted in January 2016).
.
Reason for extension? __________________________________________________________________________________
:
Office use only
Hold –
Pending the following: ___________________________________________________________________
______________________________________________________________________________________________
Denied
Reason(s):_____________________________________________________________________________
_____________________________________________________________________________________________
Approved
____________________________________________________________________________________
Effective start date: ________________________
Expected return date: _______________________
__________________________________________________
Date:_________________________
Lee Miller, M.D., Associate Dean or Meredith Szumski, Ed.D.
Enrollment Status _____
Expected Grad Date _____
of Status Entry _____
Start date – memoranda _______
SRS _____
MyCourses ______
ListServ _____ SOM/Housing Notification _____
FAO Notification _____
Main Campus ______
Academic/Clinical File Revised _____
10/2015
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