Application For Special Leave Of Absence Without Pay Form

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INSTRUCTIONS: This form is completed by the staff member and is processed through the Executive
Committee. If the request is approved, the completed form is forwarded to the Human Resources Office
and a Personnel Action Form is prepared.
Name____________________________________ Title______________________________________
D epa rtment__________________________________________________________________________
Retirement System:
______ TIAA
PROPOSED DATES OF LEAVE: From_____________________________To___________________
PREVIOUS LEAVES: Please list all previous leaves of absence for one semester or more. Attach
additional sheets if necessary.
PURPOSE OF REQUESTED LEAVE: Special leaves of absence without pay are granted for research, writing,
creative work, study, or public service. Please give details of the nature of the work, including the names and
locations of the institutions where the work will be done, etc. Attach additional sheets, if necessary.
ATTESTATION BY APPLICANT: The information I have provided on this form is accurate. Should the stated
purpose of my leave substantially change or become unable to be accomplished, even if I have commenced my
leave, I shall immediately notify the President in writing. Should the President determine that the purpose of the
leave is no longer being served, he/she may terminate the leave, assign me appropriate duties at the college or take
other appropriate action. I understand that this leave, if granted, is subject to the following rules and conditions:
The leave is without pay and, if for one year or more, will not be credited for the purpose of movement within
the salary schedule, unless the President, in his/her discretion recommends such credit, subject to approval by
the Board of Trustees/CUNY, upon the President’s determination that the leave is being taken for a project of
such academic, scholarly, or public importance that it brings honor and recognition to the college.
Retirement credit for the period of the leave is only available to members of the N.Y.C. Teachers’ Retirement
System (TRS) and N.Y.C. Employees’ Retirement System (ERS) and only if the leave is taken for very specific
purposes. If the college wishes retirement credit to be given, it must make a recommendation to that effect. The
recommendation is only advisory and must be approved by TRS or ERS for retirement credit to be granted.
Members of TIAA who are on leaves of absence without pay are not eligible for retirement credit while on
Faculty members receiving annual leave under Article 14.1 of the PSC/CLJNY collective bargaining agreement
who take a special leave of absence without pay for one semester and are in active service during the other
semester of the academic year will receive one month’s vacation pay.
A special leave of absence without pay causes a break in service towards tenure, a certificate of continuous
employment, or a 13.3.b. appointment. During a special leave, a staff member is subject to the usual review
process to determine his/her appointment status for the next year.
ADDRESS DURING LEAVE ____________________________________________________
TELEPHONE NUMBER DURING LEAVE ____________________________________________
EMAIL ADDRESS __________________________________________________________________
FAX NUMBER ____________________________________________________________________


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