Please copy and paste the following form into Word. Then fill it out and print it off.
Indiana University Kokomo Paid Family Leave Application
To read the policy on Paid Family Leaves: https://policies.iu.edu/policies/aca-50-paid-family-leave-academic-appointees/index.html
Must be a full-time academic appointee with at one year of continuous, full-time service (visiting, adjunct, part-time, post-doctoral, and intermittent appointees are not eligible for family leave). A paid leave is available twice in a five year period. Leave period shall not exceed twelve (12) weeks.*
Requesting paid family leave of absence for the period __________________________to ____________________________
For the following qualifying reasons:
________Family formation, which includes birth or adoption of a child by the academic appointee or the academic appointee’s spouse or domestic partner. The leave must be concluded within six (6) months of the birth or placement of adopted child. Leaves for the purpose of family formation shall be at full salary. *If leave is being requested due to child birth, the full-pay medical leave plan may be combined with the paid family leave for a total of 18 weeks, providing that the birth occurs while on paid contract.
Anticipated date of birth or physical custody of adopted child:
_________Family care, which includes the primary care of an academic appointee’s spouse, domestic partner, parent, dependent child, or dependent child of the appointee’s spouse or domestic partner with a serious health condition. Written medical certification and an affidavit attesting to role of primary caregiver must accompany this application. Leaves for the purpose of family care shall be covered at the following amounts:
- Full salary for academic appointees earning salaries up to and including $125,000 annually.
- Paid leave is reduced by 1% for each $2000 in salary above $125,000 with a maximum reduction of 50%.
Family leaves normally do not count towards tenure unless the faculty member specifically requests that the time count in writing to their dean
Department Head’s Signature (if applicable)
Dean or Division Head’s Signature
Executive Vice Chancellor for Academic Affairs Signature
_____Family Leave Approved
If requested, written medical certification form was received on ________________
_____Family Leave Denied
Rev. July 11, 2018