Fillable REQUEST FOR LEAVE OF ABSENCE FORM SOUTHERN UNIVERSITY (Southern University at Shreveport)

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REQUEST FOR LEAVE OF ABSENCE FORM SOUTHERN UNIVERSITY (Southern University at Shreveport)

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REQUEST FOR LEAVE OF ABSENCE FORM
SOUTHERN UNIVERSITY SYSTEM
CAMPUS:
SUS
SUBR
SULAC
SUAREC
SUNO
SUSLA
Name of Employee:
SSN:
Address:
Phone:
Title:
Highest Degree:
Birth Date:
NO. OF CONSECUTIVE FISCAL YEARS ACTIVE SERVICE AT THIS INSTITUTION:
EFFECTIVE DATE OF LEAVE:
ANTICIPATED RETURN DATE:
Purpose of leave Requested (click one):
a.
Professional or Cultural Improvement (Must have prior approval from Chancellor)
b.
Rest and Recuperation (Statement from two (2) physicians* must be attached)
c.
Independent Study or Research Statement
d.
Military
e.
Maternity (Statement from one (1) physician* must be attached)
*must be attending physician
TYPE OF LEAVE REQUESTED (check one):
a.
with pay
b.
without pay
LENGTH OF LEAVE REQUESTED: (No. of weeks, not to exceed 36 weeks)
MANNER IN WHICH THIS LEAVE, IF GRANTED, WILL BE SPENT:
******************************************************************************************
DO YOU WISH TO RETAIN FRINGE BENEFITS? (if yes, total contribution of premium must be paid to
Human Resources/Comptroller’s Office in Advance)
Teacher Retirement
Yes
No
State Retirement
Yes
No
Group Insurance
Yes
No
Elected Supplemental Benefits
Yes
No
I hereby agree to comply with the provisions of the Southern University Board of Supervisors’
policy on leaves of absence.
DATE SIGNATURE OF APPLICANT
******************************************************************************************
PRIOR LEAVE RECORD FROM THIS INSTITUTION:
Date of Last Leave:
Purpose of Last Leave:
TYPE OF LAST LEAVE:
With pay
Amount:
Without Pay
Length of last leave:
******************************************************************************************
Signature of Chairperson Signature of College Dean Signature of Chief Academic Officer
Signature of Campus Chancellor Signature of System President
DATE DATE
******************************************************************************************
Signature of Appropriate Committee Chairperson Signature of Chairman of the Board
Date Date
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REQUEST FOR LEAVE OF ABSENCE FORM SOUTHERN UNIVERSITY (Southern University at Shreveport)

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Completed 3 February 2021

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