Application For A Partial Leave With Partial Pay Form

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THE GRADUATE SCHOOL AND UNIVERSITY CENTER
THE CITY UNIVERSITY OF NEW YORK
APPLICATION FOR A PARTIAL LEAVE WITH PARTIAL PAY
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____________________________________________
Department________________________________________________________________________________________
Retirement System:
_____TRS
_____TIAA
_____ERS
PROPOSED DATES OF LEAVE: From_______________________________ To______________________________
PERCENTAGE LEAVE:___________
PERCENTAGE PAY:___________
PREVIOUS LEAVES: Please list all previous leaves of absence for one semester or more. Attach additional sheets if
necessary.
Dates
Purpose
____________
_________________________________________________________
____________
_________________________________________________________
____________
_________________________________________________________
PURPOSE OF REQUESTED LEAVE: 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. If the leave is requested for a
reduced scheduled pursuant to the Family and Medical Leave Act (FMLA), the appropriate FMLA forms should also be
filled out and submitted.
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:
Increment credit will be given for the period of the leave.
Retirement credit for the period of the leave is determined by the pension system for members of TRS and ERS.
Members of TIAA who are on a partial leave with partial pay will be eligible for contributions based upon the salary
received during the period of the leave.
Faculty who take a partial leave with partial pay for an entire academic year will receive vacation pay in July and
August that is reduced by the same percentage as was applied during the period of the leave. If the leave is for one
semester only, the salary for the month of vacation that is attached to the leave semester will be reduced by the same
percentage as was applied during the period of leave.
A partial leave with partial pay causes a break in service towards tenure, a certificate of continuous employment, or a
13.3.b. appointment.
During a partial leave, a staff member is subject to the usual review process to determine his/her appointment status for
the next year.
Date_________________________
Signed_________________________________________________________
Applicant

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