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) Use your right arrow or tab keys to move to the next field.
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