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  • 7/8/16Version

    LEAVEOFABSENCEREQUEST

    Aleaveofabsencerequestmaybegrantedforuptooneyearatatime.Aleaveofabsencemustbeapprovedbyastudentsfacultyadviser(ordivisiondirectorinthecaseofPSLstudents)andtheViceDeanofAcademicAffairs.Theapprovalofafacultyadviser/divisiondirectorandtheViceDeanofAcademicAffairs isalsonecessaryforastudenttoresumehis/herprogramofstudy.Priortocompletingthis form,pleasesetupanappointmenttodiscussthe leaveofabsencerequestwithyourfacultyadviser/divisiondirector.FormoreinformationonSOEsLeaveofAbsencepolicy,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):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  • 7/8/16Version

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

    WithdrawfromCoursesYouwillneedtowithdrawfromanycourses(currentandfuture)inwhichyouareenrolled.Pleasecontactsoe.registration@jhu.eduifyouhaveanyquestionsaboutthisprocess.

    PayYourBillsStudentsareresponsibleforpayingalltuitionandfeesontheiraccount. FinancialAidYoumayhavetobeginpayingbackyourloanwithinterestwhileonleaveofabsence.

    PleasecontacttheFinancialAidofficeatsoe.finaid@jhu.eduforfurtherinformation. JHUStudentHealthInsuranceYouwillreceivecoveragefortheperiodforwhichyouhavealreadypaid.

    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:RegistrarsOffice(StudentFile)______

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