draft student checklist and form - Rackham Graduate School

Leave of Absence Policy 

For Ph.D. Students 

Preliminary and Advisory 

For Review Purposes 

Rackham Graduate School 

CE Registration Workgroup, 12-9-09 

Leave of Absence Student Checklist 

Initial Request for a Leave of Absence 

Students on leaves of absence suspend their active study for an entire term or more and are not making progress 

towards their degree during that time. Students apply for a leave of absence which is granted by Rackham when 

the request is in accordance with the leave of absence policy. The student is not registered during the term of a 

leave of absence yet remains in compliance with the Continuous Enrollment policy. 

As a Ph.D. student, there may be alternatives to a Leave of Absence (LoA). Click here for some options to 

consider and discuss with the faculty and staff in your graduate program. 

The leave of absence process is designed to protect your privacy. Forms requesting sensitive information 

are submitted directly to Rackham. Forms shared with your graduate program are for academic planning 

purposes only. 

If you request a leave of absence, you are not required to disclose any personal details related to your 

request to your graduate program community (faculty, staff, and students). It is your decision whether to 

disclose any details about the reason you need a leave to your graduate program community. 

Staff members in Rackham are available to provide information and guidance to you about the leave of 

absence process. They can help you understand the process, requirements, and alternatives to leaves. You 

can consult with Rackham staff before making a decision to request a leave of absence so that you can get 

answers to any questions and concerns you may have. Call xxxxxx or e-mail yyyyyyy to schedule a time 

for a phone or in-person conversation. 

Student Checklist: 

□ Notify your graduate chair or faculty advisor if you are experiencing a personal or family emergency that may 

necessitate your taking a leave. You should notify your graduate chair or faculty advisor as soon as possible of 

your absence due to emergency circumstances. You should apply for the leave as soon as practicable once the 

emergency circumstances attenuate. 

□ (If you are an international student) Meet with an International Center Student/Scholar Advisor to discuss how 

immigration regulations will impact the proposed leave of absence 

□ Meet with the graduate chair or faculty advisor of your program to: 

□ Discuss alternatives to a leave of absence 

□ Determine the appropriate type of leave of absence 

□ Review the implications (academic and financial) of a leave of absence 

□ 

Discuss how courses will be noted on your transcript if you begin a leave after the first day of the term 

□ Involve your faculty advisor in the leave of absence discussion, when applicable 

□ Discuss a tentative re-entry plan, which should include: 

• The expected return date and term 

• The deadline for informing your program about your intent to return 

• Funding arrangements upon return 

• Work load expectations upon return 

• Plans to complete work from previous terms 

□ If you have student loans, talk with Office of Financial Aid staff to determine your loan deferral status while 

you are on a leave of absence 

□ If you have a scholarship or fellowship, contact a Rackham Fellowships Officer to discuss possible 

implications (call 764-8119, or e-mail flwships@umich.edu)





□ Submit leave of absence forms: 

□ 

□ 

Leave of Absence Request Form – submit the form with the student sections completed to the graduate 

chair. He or she will complete the form and submit it to Rackham’s LoA office. 

Supplemental forms are required for the following leaves of absence and are submitted directly to the 

Rackham-LoA office 

□ 

□ 

□ 

Rackham Staff will: 

Medical Reasons – Requires your health care provider to complete the form and submit it directly to 

the Rackham-LoA office 

Military Service – Include documentation confirming induction or authorization for military service 

Family Necessity or Dependent Care Form 

Provide support to you and faculty and staff in your graduate program 

Help you navigate University services and resources 

A Rackham dean will review the LoA request forms and documentation and the graduate chair’s 

recommendation 

o If you are requesting a LoA for medical reasons, a Rackham dean or designate will have 

University health professionals review your application 

Make and communicate decisions – you and the program will receive an e-mail within 7 days 

Ensure privacy and security 

We care about your privacy. The information we collect about you is private. Only people who have 

both the need and the legal right may see your information. Unless you give us permission in writing, 

we will only disclose your information for purposes of treatment, payment, business operations, 

appointment reminders, public health and safety and when we are required by law to do so. 

Your personal information will be safeguarded. The information we collect about you is private. We 

are required to protect your personal information against reasonable anticipated threats and hazards to 

the security or integrity of the information. 

As a Ph.D. student, the following alternatives to a Leave of Absence may be available: 

Resources that may be able to help you remain registered: 

o 

o 

o 

o 


CE Registration Workgroup, 12-9-09 

Rackham has a list of resources relating to a student’s academic and personal life 

Office of Financial Aid may be able to provide suggestions for funding resources 

Rackham has a designated Resolution Officer to provide advice and informal mediation for 

students 

Programs may have discipline-specific advice and resources to offer students 

Discuss possible alternatives to a leave of absence with your graduate chair and your faculty advisor. 

Some alternatives may not be available to international students; please consult with the International 

Center early in the process, before finalizing arrangements. 

o 

An accommodation to allow you to remain registered in the current term. Options would include: 

• Reducing coursework, research, teaching or other educational responsibilities 

• Working at a slower pace 

• Delaying milestone deadlines





o 

o 

• Taking incompletes in the current term with a plan to address them 

Rackham's Parental Accommodation policy may apply if you or your spouse or partner has given 

birth or adopted a child 

Under Rackham’s Within-Semester Medical Accommodation, students who have a brief illness 

or other health-related difficulties during the term should expect that faculty and programs will 

make reasonable accommodations for course-related work and other academic deadlines 

A leave of absence may be requested after the first day of the term. The start date of the leave will determine how 

courses are noted on the transcript. 

If the leave begins before the end of the drop/add period, courses will not appear on the transcript. 

If the leave begins after the drop/add period, courses will be notated permanently with a “W” for each 

course. The Registrar’s Office publishes each year’s drop/add deadlines. 

If you are granted a leave of absence, there may be implications while you are on a leave of absence: 

Students who reside in University Housing need to meet with Housing staff to discuss their options for 

continued residency, contract renewal, or contract cancellation. 

You will retain access to: 

the International Center; 

your University e-mail account, storage space in your IFS home directory, and to University websites that 

require authentication with a Login ID; and 

the University’s libraries, including borrowing privileges and remote access. 

You may be able to purchase: 

an extension of existing health insurance coverage at personal expense; 

access to Recreational Sports with a continuing student pass at personal expense; and 

access to the University Health Service (UHS) at personal expense through the UHS Prepaid Plan. 

You are not eligible: 

for University-administered fellowships, grants, temporary student employment or any of the following 

appointments: Graduate Student Instructor, Graduate Student Research Assistant, or Graduate Student 

Staff Assistant; 

for University grants or reimbursements for supplies, materials, travel or other expenses; 

to apply for new student loans intended to span the period of non-enrollment, but may defer repayment of 

existing federal student loans for up to 180 days if you meet the federal requirements for deferral. To 

confirm your eligibility for loan deferrals you should call or meet with the Office of Financial Aid to 

discuss the specific implications of a leave of absence for your circumstances; 

to newly enroll in either GradCare or the Domestic Student Health Insurance Plan; 


CE Registration Workgroup, 12-9-09





to access elements of the basic computing package including statistics and computation services on 

University UNIX systems, or printing in Campus Computing Sites or University Libraries; 

for accommodative services provided by the office of Services for Students with Disabilities; or 

to access services provided by Student Legal Services. 

You will have access to the University services that assist you in making the transition to and return from a leave 

absence, including: 

consulting with the office of Services for Students with Disabilities to plan for your return. 







If you have questions about the implications of a leave of absence, or want to confirm your understanding of your 

own circumstances, please consult the appropriate office(s): 

Academic Human Resources 

Phone: (734) 763-8938 

http://hr.umich.edu/acadhr/ 

Rackham - Leave of Absence 

Phone: (734) xxx-xxxx 

yyyyyyyy@umich.edu 

Counseling and Psychological Services 

Rackham - Resolution Officer 

Phone: (734) 764-8312 Phone: (734) 647-7548 

tdsevig@umich.edu 

gradstudentlife@umich.edu 

Dean of Students 

Recreational Sports 

Phone: (734) 764-7420 Phone: (734) 763-0050 

deanofstudents@umich.edu 

recsports@umich.edu 

HR/Payroll Service Center 

Registrar’s Office 

Phone: (734) 615-2000, (866) 647-7657 Phone: (734) 647-3507 

http://www.ro.umich.edu 

International Center 

Phone: (734) 764-9310 

Services for Students with Disabilities 

icenter@umich.edu Phone: (734) 763-3000 

sswdoffice@umich.edu 

Office of Financial Aid 

Phone: (734) 763-6600 

Sexual Assault Prevent. Awareness Ctr. 

financial.aid@umich.edu Phone: (734) 998-9368 

sapac@umich.edu 

Office of the Ombuds 

Phone: (734) 763-3545 

Spectrum Center 

Ombuds-DSA@umich.edu Phone: (734) 763-4186 

spectrumcenter@umich.edu 

Office of Student Conflict Resolution 

Phone: (734) 936-6308 

University Health Service 

Phone: (734) 764-8320 

Rackham - Graduate Student Parental Accommodation ContactUHS@umich.edu 

Phone: (734) 647-7548 


Rackham - Health and Wellness Initiative 

Phone: (734) 647-7548 


University Housing 

Phone: (734) 647-3048 

housing@umich.edu 







Leave of Absence Request Form 

Students on leaves of absence suspend their active study for an entire term or more and so are not making 

progress towards their degree during that time. Students apply for a leave of absence which is granted by 

Rackham when the request is in accordance with the leave of absence policy. The student is not registered during 

the term of a leave of absence yet remains in compliance with the Continuous Enrollment policy. 

A student may request a leave of absence for medical reasons, family necessity or dependent care for up to two 

consecutive Fall or Winter terms, or 12 consecutive months. An extension may be requested for up to an additional 

12 months, for a maximum leave of 24 months. A leave of absence for military service will be granted for the 

duration of the military service obligation. A student may request a one-term non-renewable leave of absence for 

personal reasons. 

Please use this form to initiate a request for a leave of absence, or to change the type of leave of absence. 

□ Initial Request 

Student’s Name: 

Graduate Program: 

□ Change of leave type 

Student’s UMID: 

Student’s Uniqname: 

Please indicate the type of Leave of Absence you are requesting (select one): 

□ Medical Reasons * □ Family Necessity * / Dependent Care * 

□ Military Service * 

□ Personal Reasons 

* Requires supplemental documentation on forms available at 

Please indicate the date and term that you are requesting a leave of absence to begin: 

Date: Term(s): □ Fall Term (year) □ Winter Term (year) 

Leaves of absence are granted through the end of a term so expected return dates are at the beginning of the next 

term following the conclusion of your leave. Please indicate the month and year that you anticipate returning to 

active study: □ January 1 □ May 1 □ September 1 Year 20 

Are you a US Citizen or Permanent Resident? Yes / No 

If yes, please continue to page 2. 

If you are an international student with U-M provided immigration documents you must consult 

with the International Center about possible legal implications. 

To be completed by the International Center: 

□ 

I certify that the proposed leave of absence is permissible under immigration regulations. 

□ 

The proposed leave of absence can only be taken outside the United States. The student has 

been advised on a required departure date. The student has also been advised on the impact of 

the proposed leave of absence including potential implications for future employment 

eligibility, ability to re-enter the U.S., etc. 

International Center Staff Signature: 

Printed Name: 

Date: 







I understand the implications of taking a Leave of Absence from my Ph.D. program. I understand that my 

request for a Leave of Absence may or may not be approved by Rackham. If approved, I will need to 

consult with the graduate chair to finalize my re-entry plan when I am ready to return to active study. 

I understand that I am expected to return to active study by the date indicated here or request and be 

granted an extension. If I do not return by the agreed on date, I will be presumed to have discontinued 

participation in the Ph.D. program, and will be ineligible to resume study without applying for 

reinstatement. 

Student’s Signature: 

Date: 

I have met with the student to review the implications of a leave of absence. 

□ I recommend that Rackham approve the student’s request for a leave of absence. The student and the 

graduate program have created a tentative re-entry plan for the student to return to active study. The 

agreed upon date for the student to return to active study is: 

□ I do not recommend that Rackham approve the student’s request for a leave of absence. 

Please explain recommendation: 

Graduate Chair Signature: 

Date: 

Privacy and Security Statement 

We care about your privacy. The information we collect about you is private. Only people who have both the need 

and the legal right may see your information. Unless you give us permission in writing, we will only disclose your 

information for purposes of treatment, payment, business operations, appointment reminders, public health and 

safety and when we are required by law to do so. 

Your personal information will be safeguarded. The information we collect about you is private. We are required 

to protect your personal information against reasonable anticipated threats and hazards to the security or integrity 

of the information. 

Send/Fax signed form to Rackham – Leave of Absence Office 

1530 Rackham Building, 915 E. Washington Street, Ann Arbor, MI 48109-1070 

Phone: (734), Fax: (734)

draft student checklist and form - Rackham Graduate School

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?