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Application for Leave of Absence Without Salary
This recommendation is to be completed by the applicant, signed by the department head, and submitted to the Dean. Final approval of leaves of absence without salary is the responsibility of the Dean. Forms should be submitted to the Office of the Dean no later than May 15 for a leave beginning Fall Semester and November 1 for a leave beginning Spring Semester.
Name ____________________________ Date of Application ______________________
Dates for which leave is requested*:
Beginning Date __________________ to Ending Date _____________________________
Dates and type of leaves within previous five years, if any:
_______________ to _________________: Type: _______________________________
_______________ to _________________: Type: _______________________________
*A leave of absence without salary normally will not exceed twelve consecutive calendar months. It may not exceed a maximum of twenty-four consecutive calendar months (excerpt HR-16).
State explicitly on an attached sheet the reasons for the leave request and benefits to self and university to be expected from the leave. Based on the reasons listed, the type of leave (either personal or formal study) will be determined by the Dean.
Because faculty are on 36 week (academic year) appointments and summer checks are for academic year work, faculty on fall unpaid leave will not receive salary checks from July through December and those on spring unpaid leave will not receive salary checks from January through June.
Signature of Applicant: ___________________________
FOR DEPARTMENT HEAD OR DIRECTOR WITH BUDGET AUTHORITY:
What arrangements will be made to cover applicant's responsibilities in his or her absence?
NOTE TO DEPARTMENT HEAD:
Your approval indicates that you believe the leave is worthwhile and that you can cover the faculty member's responsibilities (including a full teaching load) through the standard salary released to the department from this temporary vacancy.
Recommended by:
Department Head or Program Director ___________________________ Date______________________
Approved by:
Dean ____________________________________ Date ______________________
Revised LA 9/16/96