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____________________

Absent from___________________ to_____________________

Purpose of leave, name of conference, place, title of paper, etc.

 

 

 

 

 

Should this information be publicized in the Engineering News?

Yes_____ No_____

Where you can be reached in an emergency:

Address_____________________________

Phone______________________________

Local contact in an emergency:

Name________________________________

Address______________________________

Phone________________________________

Disposition of classes:

Course number(s)______________________

Name(s) of faculty in charge______________________________________

Signature of faculty in charge___________________________________

Disposition of advising:

Graduate________ Undergraduate________

Name(s) of faculty in charge_________________________________

Signature of faculty in charge__________________________________


Signed, Department Chair__________________________________

Date________________________