Medical Leave Form for Faculty

Medical Leave Form for Faculty

Please copy and paste the following form into Word. Then fill it out and print it off.

Indiana University Kokomo Medical Leave Application

ELIGIBILITY REQUIREMENTS: Must be a full-time academic appointee.

Name:___________________________________    

Department:______________________________

University ID:______________________________ 

Requesting medical leave of absence for the period

__________________________to ____________________________

If the leave needs to be extended, please contact your supervisor when you become aware of this.

Policy: In case of illness of any full-time academic appointee he or she shall be paid six weeks’ full salary during the illness and 50% for the balance of the semester in case the illness continues that long. Where prognosis for early recovery is favorable, the University may, upon recommendation of the chairperson or immediate supervisor followed by concurrence of the appropriate dean, provost or chancellor, extend the period of sick leave beyond the limits of one semester to a total maximum of six weeks at full pay and nine additional weeks at one-half pay. Beyond such periods or upon recognition that the illness will be more prolonged, the individual shall be placed on leave without pay. Time spent on medical leave counts toward service to the University.

Taken from: https://policies.iu.edu/policies/aca-49-other-leaves-absences-academic-appointees/index.html

Employee’s Signature:                                                                                         

________________________________________________________________________

Date: _____________________                                                                        

Administrative Approvals

________________________________________________________________________

 Date:_____________________

Department Head’s Signature (if applicable)                          

________________________________________________________________________

Date:_____________________

Dean or Division Head’s Signature                                             

________________________________________________________________________

Date:_____________________

Executive Vice Chancellor for Academic Affairs Signature

________________________________________________________________________

Date:_____________________

  _____ Medical Leave Approved

If requested, written medical certification form was received on __________          

  _____ Medical Leave Denied

Rev. July 11, 2018