request for leave of absence - ssl.uh.edu for leave of absence... · spring 2006 form university of...

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Page 1: Request for leave of absence - ssl.uh.edu for leave of absence... · Spring 2006 form UNIVERSITY OF HOUSTON Request for Leave of Absence Form Name: Empl ID: Position #: Department:

Spring 2006 form

UNIVERSITY OF HOUSTON Request for Leave of Absence Form

Name:

Empl ID:

Position #:

Department:

College:

Rank/Title:

Annual Salary:

FTE:

Tenured: yes no Years in Current Rank:

DESCRIPTION OF LEAVE

Type of Leave Requested: Development Unpaid Leave FMLA Leave Dates: From:

To:

Duration of Leave(# of semesters):

Pay Status: With Pay Without Pay Half Pay

Purpose of Leave (Be specific – Attach additional sheet if necessary):

Normal Course Load:

How Courses Will Be Covered:

For Tenure Track Positions Please indicate the anticipated year of mandatory review for:

Third Year

Sixth Year

PREVIOUS LEAVES Type of Leave Dates Paid / Unpaid

From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

APPROVALS __________________________________ ___________ __________________________________ ___________ Faculty Member Date Department Chair Date __________________________________ ___________ __________________________________ ___________ Dean Date Senior Vice President for Date Academic Affairs and Provost