APPLICATION FOR LEAVE OF ABSENCE
(Academic Staff)
Name
Department
School
Email Address
Employment Start Date
Leave Dates (exact dates –
dd/mm/yy)
Type of Leave
From:
Paid
To:
Unpaid
1. What is the purpose of the leave request?
2. The following changes to my timetable of teaching or tutorial duties would be
necessary
Timetable:
School duties:
Supervision of
Research
Students/Group:
3. Please complete the section below if the proposed leave of absence is greater
than one week
List all previous
periods of leave of
absence in the
last 3 years:
What publications
resulted from your
last period of
leave?
Only in cases of unpaid leave:
I understand that the employer will bear the employer pension costs of unpaid
leave only after I have been employed for a minimum of five years, and only if I
continue my pension contributions during my period of unpaid leave. I also
understand that the college will not pay towards pension costs for any further
periods of unpaid leave for another seven years after the date of return from the
last period.
I understand that if I take unpaid leave within first five years of employment or
another period within seven years from the last I shall be required to pay the
employee and employer pension costs in order to maintain pensionable service.
I also understand that if I elect to continue pension contributions I must pay these
on a monthly basis or as a lump sum prior to the start of my period of unpaid
leave.
I elect to continue pension
contributions during period of unpaid
leave
Yes
No
I will pay the contributions on a
monthly basis and understand these
payments must be received prior to
the 27th of each month
Yes
No
I will re-pay the amount as a single
lump sum prior to my period of
unpaid leave
Yes
No
Signature of Applicant:
APPLICANT CONFIRMATION
I understand that Leave of Absence is made available primarily for the benefit of
the College and that if subsequent to any agreement for paid or unpaid leave, my
circumstances change and I give notice of my intention to leave the College, that
any agreement for such leave may be rescinded by the College.
Signature of Applicant:
FOR COMPLETION BY ASSISTANT DEAN
Name of Assistant Dean
Signature of Assistant Dean
Date
FOR COMPLETION BY EXECUTIVE DEAN
Name of Executive Dean
APPROVED
Yes
No
Only for unpaid leave – are pension
costs being covered by school
Yes
No
Signature of Executive Dean
Date
Any comments
Please send a copy of this completed form to Human Resources