David Geffen School of Medicine at UCLA LEAVE OF ABSENCE REQUEST FORM A student may be granted a leave of absence (LOA) of one year with possible extension for one additional year. All leaves will be for a specified period of time and must be approved by the Associate Dean for Student Affairs. For medical leave - please use Medical Leave of Absence Request (MLOA) First & Last Name (printed clearly): ______________________________________ UID: ____________________________ Current Telephone #: _______________________________ STUDENT CHECKLIST  Return completed LOA form and supporting documentation (i.e. copy of research / program acceptance letter) to the Registrar via email at [email protected], fax (310) 794-9574 or in person (12-159 CHS);  If you receive financial aid it is strongly advised you visit this Financial Aid link to learn how your leave affects your current financial aid eligibility. It is your responsibility to familiarize yourself with the Leave of Absence & Withdrawals & SAP Policy;  Update your current mailing address and phone # at https://www.medstudent.ucla.edu/chngaddr/and www.ursa.ucla.edu;  I understand that should I not fulfill my USMLE requirements, as applicable, my request for a leave is null and void and may require my return to the curriculum or the changing of my leave to an Administrative Leave. Program Affiliation: Class Level: DREW/UCLA UCLA UCR/UCLA DREW/PRIME UCLA/PRIME UCR/PRIME 1st Year 2nd Year 3rd Year Requested leave date (Month, Day & Year): __________________ UCLA/MSTP 4th Year Anticipated return date (Month & Year):_________________ LEAVE CATEGORY Academic Educational MSTP MD/MBA MD/MPH Personal (Family Emergency) MD/MPP Financial Pursuit of another degree (i.e. Ph.D., J.D., MBA, MPH, etc.) Other ______________________________________ _________________________________________ ___________________________________________ Research NIH Doris Duke HHMI ____________________________________________ Other___________________________________ I have considered all academic and financial ramifications of my request, effective on the date I have requested. Student Signature: _______________________________________ Date: _________________ Office use only  Hold – Pending the following: ____________________________________________________________________________________  Denied Reason(s):____________________________________________________________________________________________  Approved ____________________________________________________________________________________________________ __________________________________________________ Lee Miller, M.D., Associate Dean or Meredith Szumski, Ed.D. Leave Category:  MSTP  Research  Personal  Financial  MD/MBA (Concurrent Degree)  MD/MPH (Concurrent Degree) Date: ________________________  Other _________________________________________  MD/MPP (Concurrent Degree) Effective leave start date: __________________________ Return as a:  1st Year/  Repeat Indicate Dual Degree _____  ListServ _____ SRS __ __  MPH  MPP Expected return date: ___________________________  2nd Year/  Repeat  3rd Year/  Repeat  of Enrollment Status _____  Expected Grad Date _____ SOM/Housing Notification _____  MBA FAO Notification _____ Start Date-Memoranda _____ Main Campus ______  4th Year/  Repeat  of Status Entry _____ Academic/Clinical File Revised ____ 8/2014