LEAVE OF ABSENCE REQUEST

College of Arts and Sciences ▪ Georgia State University

Name: / Title:
Empl ID #: / Date employed:
College: / College of Arts & Sciences / Department:
Current salary: / Contract Type (check one): / AY FY
Budget page: / Tenure Status (check one): / Tenured
Non-Tenured On Track
Non-Tenured Not on Track / Number of academic years of service:
Position Number:
Previous leaves: / From: / To: / Type/Reason:
From: / To: / Type/Reason:
From: / To: / Type/Reason:
New leave request: / From: / To: / Type (check one): / WithPay Without Pay
If leave with payplease indicate salary distribution for the leave period (*attach award letter):
Salary amount to be paid by GSU:
Salary amount to be paid by external funding:
Purpose of leave summary(please attach full proposal that meets the requirements of the A&S Professional Leaves Policy):
Leave-related external funding (attach funding proposal):: / Funding agency/source: / Funding type (e.g., course buyout, travel & living expenses, research support):
Status (check one): Funded Pending Not funded
AGREEMENT:I, the undersigned petitioner for leave, do hereby agree that I shall return the full amount of compensation received from the institution while on leave if I should not return to the institution for at least one year of service after the termination of my leave.
Petitioner’s signature: / Date:
Leave recommended by: / Signature: / Date:
Chair/ Director:
Associate Dean
Dean of School or College:
Vice President for Business and Finance:
Vice President for Academic Affairs/Instruction:
President:

INSTRUCTIONS

RECOMMENDATION FOR LEAVE OF ABSENCE FORM

College of Arts and Sciences

GeorgiaStateUniversity

Petitioner:

  1. Complete and sign the recommendation for leave of absence form.
  2. Attach any relevant documentation to justify the leave of absence.
  3. Attach copy of the proposal or award document, if any.
  4. Submit form to your Chair/Director for signature and approval
  5. Submit to your department HR representative for further processing.

Chair/Director:

  1. Review and sign form indicating your approval.
  2. Submit form and attachments to your department HR representative who should keep a copy of the form for your files and submit the form to the HR Officer for Dean’s office review, approval and further processing.

Approval notification (HR Officer):

Once final approval is received from the Dean’s office and Provost/President’s Office, the HR Officer will notify all parties via email that the leave of absence request has been approved.

LOA Form 4/22/10