Faculty Leave Request Form

LADDER RANK FACULTY APPLICATION FORM FOR:

Enter Applicant's Name Here:

I request Childbearing Leave with pay (Leave with full salary for the purpose of childbirth and recovery [APM 760-25]) for the period of:
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I understand that the period of this leave (if equal to or exceeding one quarter, but not more than one year if used in conjunction with Parental Leave) will automatically be excluded from service toward the eight-year probationary period for assistant professors. I further understand that if I do not want the period of this leave excluded I must inform my department chair in writing before, during, or within one quarter after my leave. (APM 133-17.g[3])

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   Applicant’s Initials

I request Active Service-Modified Duties (ASMD) for the period (runs contiguously with childbearing leave [APM 760-28]):
       to

To be eligible, you must be responsible for 50 percent or more of the care of a newborn child or a child newly placed for adoption or foster care. The child may be your child or that of your spouse or domestic partner

Birth mothers: You are eligible for a total period of childbearing leave plus active service-modified duties of three quarters. If you give birth during the summer or an off-duty term, you are eligible for three quarters of active service-modified duties.

Non-birth parents: You are eligible for a total period of active service-modified duties of one quarter.

I understand that active service-modified duties is a period during which my normal duties are reduced so that I may prepare for and/or care for my newborn child or my child newly placed for adoption or foster care. I also understand that a period of active service-modified duties is not a leave of absence and is included as service toward the eight-year limit:

I certify that I am responsible for 50 percent or more of the care of my child, or the child of my spouse or domestic partner.

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Signature / Date

My Department Chair and I agree that my modified duties will be:

I request Parental Leave without pay for the period: to

For Part-Time include percent time w/out pay %

I understand that I am eligible for a full-time or part-time parental leave without pay for up to one year to care for my child, or the child of my spouse or domestic partner. (APM 760-27). I understand that the period of this leave (if equal to or exceeding one quarter, but not more than one year) will automatically be excluded from service toward the eight-year period. I further understand that if I do not want the period of this leave excluded I must inform my department chair in writing before, during, or within one quarter after my leave. (APM 133-17.g[3]).

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Applicant’s Initials

I request Extension of my Tenure Clock as a result of the birth or adoption of my child. I certify that I am responsible for 50 percent or more of the care of my child (or a child newly placed for adoption or foster care), or the child of my spouse or domestic partner (APM 760-30). I understand that this certification must be made by me within two years of the birth or adoption of the child, and may not be made after July 1 of the year in which my tenure review is scheduled.

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Signature / Date

While this request will act to defer your tenure review by one year, it will not delay the timing of a merit or reappointment review. You may contact your divisional coordinator to discuss a one-year deferral of your mid-career appraisal. This request does not preclude earlier reviews if you so request.

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Applicant’s Initials

When parental leave is combined with childbearing leave, family and medical leave, and/or Active Service-Modified Duties, the total combined period shall not exceed one year for each birth or adoption. A maximum of two years may be excluded from the eight-year limit for an Assistant Professor. If the applicant holds tenure, reference to appraisal and tenure review should be disregarded.

Upon signature of both the applicant and the department chair, this form shall be submitted to the cognizant dean for approval. Upon approval, copies of both this form and the dean’s notice of approval shall be forwarded to the applicant, the applicant’s department and to the Academic Personnel Office.