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