ࡱ > P S O J) bjbjVV 4. < < f @ : : } } A A A U U U 8 D $ U 68 & I' T ' , 7 7 7 7 7 7 7 : < 7 E A P( % & " P( P( 7 } } : 7 F- F- F- P( R } R 8 7 F- P( 7 F- F- V 5 @ " ) y6 X, U ( R 6 7 8 0 68 %6 T H= ( n H= y6 H= A y6 ' ' F- ' ' Y ' ' ' 7 7 b+ ' ' ' 68 P( P( P( P( H= ' ' ' ' ' ' ' ' ' : C : Request for Leave Without Salary
Additional requirements for and limitations on Leave Without Salary are specified in the ϲʷ¼/UPI Agreement 2010-2015, Article 17 (Unit A) and 31 (Unit B) for bargaining unit employees or the Board of Trustees Regulations Section II.B.12.H. for non-bargaining unit employees. Note: Requests must be submitted at least six months prior to the starting date of the requested leave for bargaining unit employees, three months prior to the starting date of the requested leave for non-bargaining unit employees. For UnitA employees, time spent on leave without salary may be credited toward eligibility for retention, tenure, promotion, sabbatical, and PAA if requested by the employee by the end of the fourth week after the employees return to full-time employment (Article 17.5.a.).
Name: FORMTEXT D e p a r t m e n t : F O R M T E X T
R a n k : F O R M T E X T P e r i o d o f r e q u e s t e d l e a v e : F O R M T E X T
R e a s o n f o r R e q u e s t : ( C h e c k a n d p r o v i d e p e r t i n e n t d e t a i l s )
F O R M C H E C K B O X P e r s o n a l F O R M C H E C K B O X R e s e a r c h F O R M C H E C K B O X A d v a n c e d S t u d y F O R M C H E C K B O X P r o f e s s i o n a l D e v e l o p m e n t F O R M C H E C K B O X P u b l i c S e r v i c e
P u r p o s e / N e e d f o r l e a v e : F O R M T E X T
S i g n e d D a t e :
( A p p l i c a n t )
A p p r o v a l s :
D e p a r t m e n t C h a i r p e r s o n / D i r e c t o r : R e c o m m e nd _____ Not Recommend _____
Signature Date
Dean: Recommend _____ Not Recommend _____
Signature Date
Appropriate Vice President: Recommend _____ Not Recommend _____
Signature Date
Forward the original copy of this form to the Provosts Office for distribution.
April 2011
NOTE: During the leave without salary period, an employee may contribute toward and receive LIFE INSURANCE, HEALTH INSURANCE, and RETIREMENT CREDIT. ! " w 4 5 : ;
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8@ 8|x x ] ^8`|a$gd8 To enact any of these options, check with the Benefits Office, Sherman Hall 312, prior to your leave in order to determine available benefits during the leave period.
For Business Use Only
Distribution by Provosts Office:
______ Dean
______ Chair/Director
______ Employee
______ Academic Personnel
______ Personnel File
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