Application For Uft Sabbatical Leave Absence Form - The New York City Department Of Education
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1THE NEW YORK CITY DEPARTMENT OF EDUCATION
DIVISION OF HUMAN RESOURCES
MEDICAL, LEAVES & BENEFITS OFFICE
65 COURT STREET - ROOM 200
BROOKLYN, NEW YORK 11201
APPLICATION FOR UFT SABBATICAL LEAVE OF ABSENCE
I hereby apply for SABBATICAL LEAVE OF ABSENCE for the purpose and period indicated:
Purpose____________________________________From__________Through__________
If applying for more than one purpose, I request that my application be processed in the order of
priority indicated below:
(#_____) Restoration of Health
(#_____) Study/Independent Study
(#_____) Study
Name and Home Address of Applicant:
File No.
_________________________
_____________________________
Soc. Sec. No.____________________________
LAST NAME, FIRST NAME
School_______________Region_______
_____________________________
License____________________________
STREET
____________________(_________)
(________) _________________________
CITY, STATE
ZIP
AREA CODE
HOME PHONE NUMBER
---------------------------------------------------------------------------------------------------------------------
Certification by Applicant: In consideration of the grant of sabbatical leave for the purpose and period
indicated, I hereby agree to deduction from my salary of the sabbatical rate prescribed by regulations
for the period of such leave. I hereby signify my understanding that while I am on sabbatical leave, I
may not engage in gainful employment or occupation nor may I study for another trade or profession. I
understand that sabbatical leave time is not creditable toward completion of probation. I also have
completed and attached “Statement by Applicant” (Attachment 4).
Date Signed_________________Signature of Applicant________________________________
Certification by Principal or Unit Head: The foregoing application was received no later than the due
date established for sabbaticals beginning on the date shown.
Date Signed_________________
Signature of Principal_____________________________
(If other, give title)
Certification by Local Instructional Superintendent or Executive Director: The foregoing application
has been reviewed and is forwarded for verification of eligibility. If for study, the prescribed study plan
has been approved by me and the submissions required upon completion of the sabbatical leave will be
checked to ensure compliance with requirements. It is understood that approval is subject to the 5%
school quota limit or hardship provisions.
Date Signed__________________
Signature_______________________________________
Title____________________________________________
Form OP8
Division of Human Resources (Medical, Leaves and Benefits)
1
4/21/2008
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