Faculty Leave Request for Academic Year: ______

Name / Empl ID
Rank / Tenure Status
School
Department or Program / Total Percent Full-time
Reason for Leave Request
(Reason code provided for your information) / □ Research/Academic
(ACA)
□ Personal (PRS)
□ Other (MIL, OTH, TER, WCC)
Requested Leave Dates / / / through / /
Expected Return Date / / / / Expected return date must be included on appointment form.
NU Funding
(Action code provided for your information) / □Unpaid (LOA) / □Partially paid (PLA) / □Fully paid (PLA)
Dates and Reason for Last Leave
Is this a Deferred Leave? If so, provide reason for deferment.
Comments:
Dean’s Office Approval
______
Signature Date / Provost’s Office Approval
______
Signature Date

Attach supporting documentation.

Research/Academic

Standard LengthPer school policy

FundingGenerally Paid

DocumentationFaculty member request with Dean’s approval

HR Position/Appointment Form

Personal

Standard LengthN/A

FundingGenerally unpaid

DocumentationFaculty member request with Dean's approval

Start and expected End Dates

HR Position/Appointment Form

Childbearing/Adoption

Standard Length12 weeks. 10 weeks at FSM/Law.

FundingPaid

DocumentationFaculty member request with Dean's approval

Start/End dates

HR Position/Appointment Form

Childrearing

Standard Length12 weeks. 10 weeks at FSM/Law.

FundingPaid

DocumentationFaculty member request with Dean's approval.

HR Position/Appointment Form

Requests for tenure extension must be made separately.

Medical - Self/Family

Standard LengthN/A

FundingGenerally unpaid

DocumentationDoctor's Note for self; Doctor’s Note for family member

Doctor’s assurance of readiness to return to work

HR Position/Appointment Form

Military

Standard LengthN/A

FundingUnpaid

DocumentationFaculty member request with Dean's approval

HR Position/Appointment Form

*On HR Position/Appointment form submission:

Paid leave action code: PLA

Unpaid leave action code: LOA

Expected return date is required.

Separate return from leave Position/Appointment form is required upon faculty member’s return.

RFL/RFL for return from unpaid leave; RFL/RPL for return from paid leave.

**Note that Tenure Clock extension requests are separate