University of California
College of Engineering
Department of Electrical Engineering and Computer Sciences
REQUEST FOR ACADEMIC LEAVE OF ABSENCE FOR SEVEN CALENDAR DAYS OR LESS
This form should be submitted to the Department Chairman at least one week in advance of the proposed leave. For purposes of verification, faculty members that you designate to be in charge of your classes/advising during your absence must initial this form prior to submission for approval.
Name______________________________________
Date____________________
Yes_____ No_____
Address_____________________________
Phone______________________________
Name________________________________
Address______________________________
Phone________________________________
Course number(s)______________________
Name(s) of faculty in charge______________________________________
Signature of faculty in charge___________________________________
Graduate________ Undergraduate________
Name(s) of faculty in charge_________________________________
Signature of faculty in charge__________________________________
Signed, Department Chair__________________________________
Date________________________