HERBERT H. LEHMAN COLLEGE OF THE CITY UNIVERSITY OF NEW YORK APPLICATION FOR SPECIAL LEAVE OF ABSENCE INSTRUCTIONS: Form is completed by staff member and is presented through Personnel and Budget Committees. If request is approved, completed form is forwarded to the Personnel Office and a Personnel Action Form is prepared. (SSN) (TextField1) Name_______________________________ Soc. Sec. No._________________ Rank________________Department______________ Retirement _________TRS ________TIAA _________ERS Proposed dates of leave: from_________________to_________________ List all previous leaves of absence: (for a semester or more) (Attach additional sheet if necessary) Dates __________ Purpose ______________________________________ Dates __________ Purpose ______________________________________ Dates __________ Purpose ______________________________________ Purpose of requested leave: If research, writing, creative work, study, or public service, give details of nature or work, including name and location of institution where work will be done, etc. (attach additional sheet if necessary). _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ I understand that this leave, if granted, is without pay and if for one year or more will not be credited for purposes of movement within schedule. The president may recommend such credit, however, subject to approval by the Board of Trustees/CUNY, if the leave is being taken for a project of academic, scholarly or public importance that brings honor and recognition to the college. If the college wishes retirement credit to be given, it must make a recommendation to that effect. The recommendation is only advisory to the Teacher's Retirement System and must be approved by the System for retirement credit to be granted. TIAA and ERS members on leave without pay are not eligible for retirement credit while on leave. Staff members who take a special leave for one semester will receive one month's vacation. OVER Application for Special Leave of Absence - continued A special leave of absence causes a break in service towards tenure or a certification of continuous employment. During your leave, you will be subject to the usual peer review process to determine your appointment status for next year. (DateTimeField6) Date_____________ Signed_______________________________________ Address during leave______________________________________________ ______________________________________________ To be completed by the department chair: Proposed arrangement for academic work Recommendation of Department Personnel and Budget Committee _______________recommended _______________not recommended Date_____________ Signed_______________________________________ chair ================================================================== Recommendation of College Personnel and Budget Committee _______________recommended _______________not recommended _____with _____without retirement credit credit for movement _____without with schedule _____without ================================================================= Recommendation of President _______________recommended _______________not recommended Date___________ Signed_______________________________________ President or Designee ================================================================== Reviewed by OFSR/CUNY _______________approved _______________not approved Date_____________________ Signed_______________________________ 2/11 HR