Leave Of Absence Request Form

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____________________________________________
David Geffen School of Medicine at UCLA
LEAVE OF ABSENCE REQUEST FORM
A student may be granted a leave of absence (LOA) of one year with possible extension for one additional year.
All leaves will be for a specified period of time and must be approved by the Associate Dean for Student Affairs.
For medical leave - please use Medical Leave of Absence Request (MLOA)
First & Last Name (printed clearly): ______________________________________
UID: ____________________________
Current Telephone #: _______________________________
STUDENT CHECKLIST
 Return completed LOA form and supporting documentation (i.e. copy of research/program acceptance letter) to the Registrar via email at
registrar@mednet.ucla.edu, fax (310) 794-9574 or in person (12-159 CHS; M-F 8:00am – 5:00pm);
 If you receive financial aid it is strongly advised you visit the
Financial Aid & Scholarship
website to learn how your leave affects your current
financial aid eligibility. It is your responsibility to familiarize yourself with the Leave of Absence & Withdrawals & SAP Policies;
 Update your contact information (current mailing address and phone number) at MyUCLA;
 I understand that should I not fulfill my USMLE requirements, as applicable, my request for a leave is null and void and will result in the
changing of my leave to an Administrative Leave.
Program Affiliation:
DREW/UCLA
UCLA
UCR/UCLA
UCLA/MSTP
DDS
DREW/PRIME
UCLA/PRIME
UCR/PRIME
Class Level:
1
Year
2
Year
3
Year
4
Year
st
nd
rd
th
Requested leave date (Month, Day & Year): __________________
Anticipated return date (Month & Year):_________________
LEAVE CATEGORY
Academic
Educational
Personal (Family Emergency)
MSTP
MD/MBA
MD/MPH
MD/MPP
Financial
Pursuit of another degree
Other ______________________________________
(i.e. Ph.D., J.D., MBA, MPH, etc.)
___________________________________________
_________________________________________
Research
NIH
Doris Duke
HHMI
Other___________________________________
I have considered all academic and financial ramifications of my request, effective on the date I have requested.
Student Signature: _______________________________________
Date: _________________
Office use only
 Hold – Pending the following: ____________________________________________________________________________________
 Denied Reason(s):____________________________________________________________________________________________
 Approved ____________________________________________________________________________________________________
__________________________________________________
Date: ________________________
Lee Miller, M.D. , Associate Dean or Meredith Szumski, Ed.D.
Leave Category:  MSTP
 Research
 Personal
 Financial
 Other _________________________________________
 MD/MBA (Concurrent Degree)
 MD/MPH (Concurrent Degree)
 MD/MPP (Concurrent Degree)
 MBA
 MPH
 MPP
Effective leave start date:
__________________________
Expected return date:
___________________________
Return as a:
 1
Year/  Repeat
 2
Year/  Repeat
 3
Year/  Repeat
 4
Year/  Repeat
st
nd
rd
th
Dual Degree _____ Enrollment Status _____ Expected Grad Date _____
Start Date-Memoranda _____
Change of Status Entry _____
MyCourses _____
ListServs _____ SRS __ __
SOM/Housing Notification _____
FAO Notification _____
Main Campus ______
Academic/Clinical Files ____
10/2015

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