Leave of Absence Request Form

Leave of Absence Request Form

This form will be routed to the Leaves Administration once it is submitted. A leave adviser will contact you within 2 business days.

You may be required to furnish certification in accordance with the university leave procedures to your designated leave coordinator, supervisor or other responsible administrator.

Form may be completed by the employee’s personal representative or department if the employee is incapacitated.

Request
I am requesting my leave as
I am requesting a leave for the following reason
Caring For
Covered Military Member
I am the servicemember's
If you believe you require a leave for a reason that is not listed above, please provide more information:
I am a faculty member