Unpaid Leaves Form by 2G5kbw

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									                                                Addendum to Administrative/Faculty Appointments for Unpaid Leaves


Name                                                           Employee ID               Department                                         Date
Campus          Athens        Chillicothe        Eastern       Lancaster      Southern       Zanesville         Other
I request an unpaid leave of absence from:
    Academic Yr         Fiscal Yr                                          month / day / year             TO            month / day/ year

   Family Medical Leave (FML)                                          FML-Call to Active Duty
   Employee must exhaust available sick leave and                      Provides up to 12 weeks unpaid leave for spouse, domestic partner,
   may opt to take vacation prior to using unpaid                      child or parent being on active duty or impending call or order to active
   Family Medical Leave. A health care provider's                      duty. May opt to use vacation prior to unpaid leave.
   certification form must be attached.
   Medical Leave                                                       Military
   Employee must exhaust available sick leave and                      Employee must have been employed by Ohio University ninety days prior
   may opt to take vacation prior to using unpaid                      to induction/enlistment and attach a copy of military orders or other
   Family Medical Leave. A health care provider's                      authorizing document.
   certification form must be attached.
   FML-Caregiver for injured/ill Service Member                        Educational (Administrative Staff Only)
   Caregiver leave for an injured or ill Service Member                Employee must attach certification of enrollment.
   provides 26 weeks of paid and/or unpaid leave
   for a spouse, domestic partner, child, parent or                    Faculty Professional
   nearest blood relative caring for a recovering                      Must include reason for leave (Baker Award, Distinguished Professor,
   service member. When combined with other                            Fulbright, research, other professional opportunity.)
   qualifying FML it may not exceed 26 weeks in
   a single 12 month period.                                           Personal
                                                                       Reason

Signature:
               Employee Signature                                                                                              Date

To be filled out by department/school:
   A. Ohio University       will      will not    continue University Group Insurance during the period of this leave
         not to exceed the maximum time allowed per the leave of absence policy.
   B. It is agreed that this leave of absence will have no effect on any promotion opportunities.
   C. It is understood that sick leave and vacation will not accrue during the period of unpaid leave of absence.
   D. It is the responsibility of the Employee to make the necessary arrangements with PERS or STRS for establishing retirement
             service credit for the period of this leave.
   E. It is further agreed that in consideration of the above stated benefits, the employee agrees to comply fully with the provisions
             of the unpaid leave of absence policy. (Attach any other terms and conditions of the leave to this Appointment Addendum.)
                                                               contribute the employer's share of STRS/PERS if the STRS/PERS accepts the employee's
   F. The department              will           will not
                                                               share.
   For Faculty Only:
   G. Faculty Member is                  Tenured            Non-Tenured, Tenure Track*                 Not in a tenure-track position
       *If in tenure-track, but not tenured: This period of leave             will        will NOT be considered as a part of the probationary period
   H. This period of leave               will       will NOT       be considered toward accrued time for faculty fellowship leave

        This form serves as an addendum to the employee's employment and requires signatures of approval below.

Recommend:                                                                     Remarks:
     Approval

       Disapproval
                         Chair/Director/Regional Campus Dean (name)                                 Signature                                      Date
Recommend:                                                                     Remarks:
     Approval

       Disapproval
                         Vice President/Academic Dean (name)                                        Signature                                      Date
Recommend:                                                                     Remarks:
     Approval

       Disapproval
                         Associate Provost for Academic Affairs                                     Signature                                      Date

Refer to Ohio University Policy and Procedures 40.054, 41.128 and the Ohio University Faculty Handbook for Leaves of Absence.
   ORIGINAL TO:          Payroll Office                                                  COPY TO:         University Human Resources
                         HDL Center Suite 214                                                             Human Resources and Training Center
                                                                                                                       University Human Resources (2/2009)
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