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Page 1: LEAVE OF ABSENCE REQUEST STUDENT TO …education.jhu.edu/.../SOELeaveofAbsenceRequestForm... · LEAVE OF ABSENCE REQUEST A leave of ... the Office of International Services before

7/8/16Version

LEAVEOFABSENCEREQUEST

Aleaveofabsencerequestmaybegrantedforuptooneyearatatime.Aleaveofabsencemustbeapprovedbyastudent’sfacultyadviser(ordivisiondirectorinthecaseofPSLstudents)andtheViceDeanofAcademicAffairs.Theapprovalofafacultyadviser/divisiondirectorandtheViceDeanofAcademicAffairs isalsonecessaryforastudenttoresumehis/herprogramofstudy.Priortocompletingthis form,pleasesetupanappointmenttodiscussthe leaveofabsencerequestwithyourfacultyadviser/divisiondirector.FormoreinformationonSOE’sLeaveofAbsencepolicy,pleaseviewhttp://www.students.education.jhu.edu/catalog/SchoolAdmin/registration/leave.html.

STUDENTTOCOMPLETETHISSECTIONONLY__________________________________________________________________________________LastName(Pleaseprint) FirstName StudentIDAreyouanInternationalstudent?*Yes_____No_____VisaType______________*(StudentswithF-1visasmustcontacttheOfficeofInternationalServicesbeforeleavingJohnsHopkinsUniversity.Perfederalregulations,youmaynotremainintheU.S.ifyouwishtogoonaleaveofabsenceforafinancial,family,ormedicalreasonotherthanyourown.)MailingAddress:(Ifthereareanychangestoyourcontactinformationduringyourleaveofabsenceexpires,pleaseupdateyourpersonalinformationonStudentSelf-Service)Street:__________________________________________________________________________City: ________________________________State:__________ZipCode:_______________Phone:_________________________________JHUEmail:_______________________________ProgramofStudy:_________________________________________Term/YearEntered:__________________FacultyAdviser/DivisionDirector:_________________________________________Reasonforrequestingaleaveofabsence:Academicperformance_____Personal/familyreason_____Financialconsiderations_____Medicalreasons*_____Other______*Appropriatedocumentations,(forexample,aletterfromyourdoctor)mayberequiredbeforealeaveofabsenceisgranted.Additionally,appropriatedocumentation(forexample,aletterfromyourdoctor)mayberequiredtoconfirmyourreadinesstoreturntotheuniversityandresumeyourprogramofstudy.IfyouchooseOther,pleaseexplain(detailinaseparatedocument[e.g.letter]ifneeded):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Page 2: LEAVE OF ABSENCE REQUEST STUDENT TO …education.jhu.edu/.../SOELeaveofAbsenceRequestForm... · LEAVE OF ABSENCE REQUEST A leave of ... the Office of International Services before

7/8/16Version

PleasestatethestartandendofyourrequestedLeaveofAbsence:StartSemester/Year_________________EndSemester/Year______________________**IsthisarequesttoextendaLeaveofAbsence?Yes______No______Ifyes,whendoes(ordid)yourpriorLeaveofAbsenceend?Semester/Year___________________Ifyouaregrantedaleaveofabsencepleasebeawareofthefollowing:

• WithdrawfromCourses–Youwillneedtowithdrawfromanycourses(currentandfuture)inwhichyouareenrolled.Pleasecontactsoe.registration@jhu.eduifyouhaveanyquestionsaboutthisprocess.

• PayYourBills–Studentsareresponsibleforpayingalltuitionandfeesontheiraccount.• FinancialAid–Youmayhavetobeginpayingbackyourloanwithinterestwhileonleaveofabsence.

PleasecontacttheFinancialAidofficeatsoe.finaid@jhu.eduforfurtherinformation.• JHUStudentHealthInsurance–Youwillreceivecoveragefortheperiodforwhichyouhavealreadypaid.

CheckwithOfficeofStudentAffairsregardinginsurancequestionswhileonleave.Whenyouarereadytoreturntoyourstudies,pleasecontactyourfacultyadviser/divisiondirectorforguidance.StudentSignature:_______________________________________________Date______________ThissignatureverifiesthatyouhaveprovidedaccurateinformationandunderstandyourfinancialandlegalobligationstotheJohnsHopkinsUniversitySchoolofEducationduringyourleaveofabsence.Onceyoursectionoftheformiscomplete,pleasesubmittheformtoyourfacultyadviser/divisiondirector.Youwillreceiveasignedcopyofthisformnotifyingyouwhetheryourrequestforaleaveofabsencehasbeengranted.

OFFICEUSEONLY

FacultyAdviser/DivisionDirectorApproval

LeaveofAbsenceGranted:Yes____No____

StartDateofLeaveofAbsence:___________LeaveofAbsenceApprovedUntil:___________

PrintName:____________________________________________________

Signature:______________________________________________________Date:________________________

ViceDeanofAcademicAffairsApproval

LeaveofAbsenceGranted:Yes____No____

PrintName:____________________________________________________

Signature:______________________________________________________Date:________________________

Copiesofthisdecisionformshouldbesentto:FacultyAdviser/DivisionDirector____ViceDean________StudentAffairs____OIS(forinternationalstudentsonly)____

TheoriginalLeaveofAbsenceRequestformshouldbesentto:Registrar’sOffice(StudentFile)______


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