Request For Approval Of Leave Of Absence From Campus Form

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Electrical Engineering Department
REQUEST FOR APPROVAL OF LEAVE OF ABSENCE FROM CAMPUS
For the Period of Less than or Up to Seven (7) Calendar Days
This form needs to be approved and signed by the Department Chair or the designee at least three days prior to the leave.
For an absence of more than seven (7) days, the Green form (UPAY 573) must be submitted for the Chair’s and the Dean’s
approvals at least one week prior to the leave.
gen\in\lofa
SECTION 1: For All Travelers
Name: ____________________________________________________ Date: _________________________________
Period of Absence: From __________________ To ____________________
Destination: ______________________________________________________________________________________
Reason for Absence:
[ ] Attend and/or present at Professional Conference(s) or Meeting(s):
Date:
Place:
Title of Conference/Meeting
________________ _______________________
______________________________________________
________________ _______________________
______________________________________________
________________ _______________________
______________________________________________
[ ] Other Business: (Explain) _________________________________________________________________
____________________________________________________________________________________________
[ ] Illness
[ ] Other Personal: ___________________________________________________________
Type of Leave:
[
] With Full Salary
[
] Without Salary
Fund Support Requested: [
] None
[
] Transportation
[
] Subsistence
[
] Cash advance (if applicable): $_________________
Budget(s) to be charged: Name
Acct. No. ______________________________________
Name
Acct. No. ______________________________________
SECTION 2: For Faculty and Professional Research only
Period affected by leave:
[ ] Summer Quarter
[ ] Service Period
[ ] Sabbatical
[ ] Quarter with no schedule teaching assignment
Disposition of work during Absence:
Course ____________ Class meets ________________ Substitute Instructor _________________________________
Course ____________ Class meets ________________ Substitute Instructor _________________________________
Assigned responsibilities: ____________________________________________________________________________
SECTION 3: Signatures
Form prepared by: ______________________________
__________________________________________________
(print name)
Applicant’s Signature
Date
_______________________________________________
__________________________________________________
P.I.’s or Fund Authority’s Signature
Date
Chair’s Signature
Date

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