Fillable Form 36609 - Request For Leave Of Absence printable pdf download

Form

REQUEST FOR LEAVE OF ABSENCE

36609

Page 1 of 2

PERSONAL INFORMATION

Faculty/Staff Member to return completed form to supervisor/department chair.

Last Name:

First Name:

Middle Name:

Department:

UMID:

Title of Position:

LEAVE OF ABSENCE INFORMATION:

Department Address:

Supervisor’s/Department

Date of Request:

Supervisor’s/Department Chair’s Name:

Supervisor’s/Department Chair’s Signature:

FACULTY/STAFF MEMBER:

Check the type of leave, supply the required information in writing, and provide attachments as indicated.

Reference Standard Practice Guide 201.30 and 201.30-1, Leaves of Absence. NOTE: Faculty and Staff represented by a Union should refer to

the collective bargaining agreement that governs the terms and conditions of their employment for information regarding leaves of absence.

Leaves applicable to faculty and staff:

Child Care

State the date of the child’s birth, adoption, or foster placement. Date: __________________________

Educational

Indicate school and credit hours. If not a UM student, attach a completed Educational Leave of Absence Addendum,

available at , to verify registration.

Attach U.S. Department of Labor Certification of Health Care Provider For Family Member’s Serious Health Condition

Family Care

(Family and Medical Leave Act), Form WH-380-F ( ).

Government Service

Indicate the nature and duration of the government service.

Intergovernmental

Attach OF69 Assignment Agreement. (Refer to SPG 201.30-5, Federal Personnel Agreements.)

Personnel Assignment

Military Service

Attach a copy of the Notice of Induction or Authorization for Active Duty.

Qualifying Exigency

Attach a copy of the U.S. Department of Labor Certification of Qualifying Exigency For Military Family Leave (Family and

Medical Leave Act), Form WH-384 ( ).

Attach a copy of the U.S. Department of Labor Certification for Serious Injury or Illness of Covered Servicemember -

Care of a Covered

for Military Family Leave (Family and Medical Leave Act), Form WH-385 ( ).

Servicemember

Personal Medical

If receiving Workers’ Compensation, indicate whether you want to exhaust your vacation time before the leave begins.

Medical/Child Care

Provide the date of the child’s birth. Date: ________________________ This leave is only applicable to employees

not eligible for extended sick time.

Phased Retirement

Use this form to initiate a phased retirement program. Describe the arrangement for the phased retirement program.

(Refer to SPG 201.83, Retirement.)

Personal

State the reason for requesting the leave: ___________________________________________________________

Use this form to establish the initial seasonal leave period. (Refer to SPG 201.30-3, Seasonal Leave of Absence Appointment.)

Seasonal Leave

Leaves applicable to faculty members only:

Indicate the location and duties to be performed. (Refer to SPG 201.90, Duty Off-Campus.)

Duty Off-Campus

Outside Teaching

Indicate the name of the educational institution and the duties to be performed.

Assignment

Research

State the nature of the research program, the location, and the funding source.

Phased Retirement

Indicate specific plans and effective date of combined retirement furlough and phased retirement plans. (Refer

Furlough

to SPG 201.81, Retirement Furlough and SPG 201.83, Retirement.)

Retirement Furlough

Indicate specific plans and effective date of complete retirement. (Refer to SPG 201.81, Retirement Furlough.)

Scholarly Activity

State the nature of the activity, the location, and the funding source. (Refer to SPG 201.30-4, Scholarly Activity Leave.)

I request that my leave begin on __________________________ and end on ___________________________. (If necessary, give approximate dates.)

I understand that returning to work before the leave’s expiration date is at the discretion of the University. NOTE: Assuming that I have an eligible

appointment upon my return from leave, I authorize the University to automatically re-enroll me (and my dependents, if applicable) in those Benefits

Plans in which I was enrolled as of my last day of work (prior to the leave) and to deduct any resulting costs from my earnings. My most recent benefi-

ciary designation for Group Life insurance will be continued.

Office Phone:

Faculty/Staff Signature:

Home Phone:

Home Address:

Form 36609

Revised 11/10

Available at:

Form 36609 - Request For Leave Of Absence

Related Articles

Related forms

Related Categories