Family Leave Act application
Indiana University Paid Family Leave
ELIGIBILITY REQUIREMENTS: Must be a full-time academic appointee with at least two years of continuous full-time service (visiting, adjunct, part-time, post-doctoral, and intermittent appointees are not eligible for family leave). A paid leave is available twice in a five year period. *Leave period shall not exceed twelve (12) weeks.
I, am requesting a full paid family leave of absence for the following qualifying reasons:
___________ For the birth or adoption of a child by the academic appointee or the academic appointee’s spouse or registered domestic partner, which leave must be concluded within twelve (12) months of the birth or placement of adopted child.
*If leave is being requested due to child birth, the full-pay medical leave plan may be combined with the family leave for a total of 18 weeks, providing that the birth occurs while on paid contract (does not apply to summer break for ten month academic year appointee).
____________ For the serious health condition of the academic appointee’s spouse, registered domestic partner, parent, dependent child, or dependent child or parent of the appointee’s spouse or registered domestic partner when the academic appointee is the primary or co-primary caretaker.
*Please attach a written medical certification and an affidavit attesting to the role of primary or co-primary caretaker.
Paid Family Leave being requested for the period _____________________ to _______________________.
Anticipated date of birth or physical custody of adopted child _____________________________.
Family leaves normally do not count towards tenure unless the faculty member specifically requests that the time count. An Understanding on Tenure Status form must be completed for all tenure-track faculty (http://www.indiana.edu/~vpfaa/download/leave_nontenure.doc).
Employee’s Name (Print) Employee’s Signature
Department Head’s Signature Date Dean’s Signature Date
Family Leave Approved
If applicable, written medical certification form was received on .
Family Leave Denied
Vice Provost for Faculty and Academic Affairs Signature Date