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REQUEST FOR LEAVE OF ABSENCE FORM
SOUTHERN UNIVERSITY SYSTEM
NO. OF CONSECUTIVE FISCAL YEARS ACTIVE SERVICE AT THIS INSTITUTION:
Purpose of leave Requested (click one):
Professional or Cultural Improvement (Must have prior approval from Chancellor)
Rest and Recuperation (Statement from two (2) physicians* must be attached)
Independent Study or Research Statement
Maternity (Statement from one (1) physician* must be attached)
*must be attending physician
TYPE OF LEAVE REQUESTED (check one):
LENGTH OF LEAVE REQUESTED: (No. of weeks, not to exceed 36 weeks)
MANNER IN WHICH THIS LEAVE, IF GRANTED, WILL BE SPENT:
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DO YOU WISH TO RETAIN FRINGE BENEFITS? (if yes, total contribution of premium must be paid to
Human Resources/Comptroller’s Office in Advance)
Elected Supplemental Benefits
I hereby agree to comply with the provisions of the Southern University Board of Supervisors’
policy on leaves of absence.
DATE SIGNATURE OF APPLICANT
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PRIOR LEAVE RECORD FROM THIS INSTITUTION:
TYPE OF LAST LEAVE:
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Signature of Chairperson Signature of College Dean Signature of Chief Academic Officer
Signature of Campus Chancellor Signature of System President
DATE DATE
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Signature of Appropriate Committee Chairperson Signature of Chairman of the Board
Date Date