Leave of Absence (All Taught Students) Academic Registry Student Records and Operations
This form should be used to request a Leave of Absence (temporary withdrawal) from the University. Once completed, this form should be returned to your School administrators; contact details can be found on the Student Self Service www.lboro.ac.uk/services/registry/self-service/ under My Programme and Staff Contacts. Before submitting your request, you may wish to make an appointment with Student Advice and Support to discuss the financial and Immigration implications of your request Further information about taking a Leave of Absence is available at /www.lboro.ac.uk/students/enquiries/undergraduatestudents/loa/ Please ensure that the form is completed in full and that all dates are accurate.
1. Name	2. ID Number
3. School/Department
4. Current Programme
5. Leave of Absence details An authorised academic in your School/Department will be able to talk to you about whether a Leave of Absence is appropriate/permissible. If you wish to take Leave of Absence please choose from the options under section 5.1 below. 5.1 I wish to take Leave of Absence and withdraw temporarily from the University for the following period: From: (DD/MM/YYYY) / / (date last attended) Until: (DD/MM/YYYY) / / I would like to return to the same programme on which I am studying. I would like to return to a different programme (you will also need to make a formal request via the My Requests tab in the Self-Service portal)
6. Please indicate your main reason for requesting Leave of Absence Main Reason Main Reason The course content was not what I expected Health reasons The course was too difficult Financial reasons Going into employment Other personal reasons Other/Further information (please give details about the reason for your request – continue on a separate sheet if necessary) If appropriate, you are required to include Documentary Evidence to support your claim (eg. medical record, official letter, etc.)
Yes No 7. Have you submitted a claim for Mitigating Circumstances in relation to any current year modules?
8. Please indicate below who you have discussed your Leave of Absence plans with Yes No Yes No Academic staff member in School/Department Academic Registry staff Student Wellbeing & Inclusivity/Student Advice & Support Hall Warden (if in hall) Chaplaincy, Medical Centre Accommodation Services
9. STUDENT DECLARATION I confirm that I have discussed my plans with an authorised academic in my School/Department and my agreed course of action has been indicated in section 5 above. I understand this does not constitute a release from my licence/contract for halls of residence or private sector accommodation. I further understand that I may be liable for a proportion of my tuition fee and that the University will, as appropriate, inform Student Finance /Home Office of my new circumstances and that this may have financial/immigration implications for me. I enclose (if appropriate): Documentary Evidence Print Name: Signature: Date: / /
9.1 TABLE OF PROPORTIONED TUITION FEES FULL-TIME STUDENT PART-TIME STUDENTS WILL BE CHARGED ON A MODULAR BASIS Fees are pro-rated as follows: Within 4 weeks of start of term >4 weeks but during Term 1 During Term 2 During Term 3 During Term 4 UK UG 0% 25% 50% 100% N/A Int UG 0% 33% 66% 100% N/A UK/Int PGT 0% 25% 50% 75% 100% Relevant authorities (e.g. Student Finance and the Home Office) will be informed of the student’s withdrawal. 10. TO BE COMPLETED BY THE SCHOOL/DEPARTMENT 10.1 Support for Leave of Absence (Please give your reason for supporting this request – continue on a separate sheet if necessary) 10.2 Module Details Please give details of any modules affected. N.B. Please refer to University Regulation IX, para. 40, (subs. iv, a & b) regarding the deletion / carrying forward of coursework marks. Indicate whether a waiver of Regulation IX is being sought (a separate General Regulations Waiver Form RG1012 will also need to be completed). Module Code Module Title % of Module Completed Action to be taken Coursework Exam Deleted Carried over (Student office to add back on) Request Reg. IX waiver 10.3 SCHOOL DECLARATION (to be completed by the Programme Director) I have discussed with the above student their wish to take Leave of Absence. The student has been made aware of the options available and I am satisfied with the course of action detailed in section 5 above. Print Name: Signature: Date: / / 10.4 SCHOOL DECLARATION (to be completed by the Administrator) Print Name: Signature: Date: / /
11. Dean of School (or delegated nominee – usually ADT) Authorisation Print Name: Signature: Date: / /