LOA/Extended Absence Request

UIWSOM Absence Request

D.O. Extended and Leave of Absences requests only
D.O. students, this form should only be used to submit an Extended Absence Request or a Leave of Absence Request. All short-term absence requests must be submitted through Elentra.

Extended Absence (Phase I only):
4 to 20 consecutive business days during Phase I.

Leave of Absence:
Phase I: greater than 21 consecutive business days.
Phase II: greater than 5 consecutive business days.

*Business days: Monday - Friday.
Based on the absence descriptions above, please select the option that applies to this request:

Extended Absence (Phase I only)Leave of AbsenceAbsence Related to Maternity (if a Phase I student and unsure if it will be an Extended or LOA)

Extended Absence Request
Absence Related to Maternity
Leave of Absence Request
Name*

First NameLast Name
UIW Identification Number*
UIW Email Address*

Confirmation Email
Phone Number*
Please enter a valid phone number.
Personal Email Address*

Confirmation Email
Select UIWSOM Program*

DO
Select Classification*

OMS-IOMS-IIOMS-IIIOMS-IV
First Date of Absence*

MonthDayYear
Last Date of Extended Absence and/or Absence Related to Maternity*

MonthDayYear
Date
LOA - Last Date of Absence (anticipated)*

MonthDayYear
Describe the reason for your Absence Request*

Leave of Absence
***The Leave of Absence process below applies to DO program only. MBS learners must use: UIW Leave of Absence Request

Leave of Absence - An approved leave of absence is a temporary interruption in a medical student’s program of study and is intended for a student who needs to interrupt their program of study for a period greater than 21 consecutive business days for Phase I or greater than 5 consecutive business days for Phase II. A leave of absence can be categorized as administrative, educational, or medical.

During a leave of absences, a student will be withdrawn from all UIWSOM courses as per the withdrawal policy. Campus resources and auditing courses will be at the discretion of the UIWSOM Dean.

Please review the Student Handbook for detailed information on eligibility requirements, approval process, term limits, etc.
Prior to submitting this Extended Leave of Absence Request, it is recommended to meet with the following representatives to discuss the impact of your LOA.

Phase I Learner:
- Office of Admissions and Student Affairs - Ms. Ladonna Davidson*
- Phase I Co-Director of Curriculum Integration - Dr. Jessica Bradley*
- Academic Support - Dr. Sarah Lang
- Enrollment Services - Mr. Hazim Thomas and Ms. Raisa De La Rosa
  *Discussion can be combined
Phase II Learner:
- Office of Admissions and Student Affairs - Ms. Ladonna Davidson*
- Phase II Co-Director of Curriculum Integration - Dr. Lori Kels*
- Office of Clinical Affairs - Dr. David Garza*
- Academic Support - Dr. Sarah Lang
- Enrollment Services - Mr. Hazim Thomas
  *Discussion can be combined
MPH Learner:
- Office of Admissions and Student Affairs - Ms. Ladonna Davidson
- MPH Director - Dr. Robyn Phillips-Madson
- Enrollment Services - Mr. Hazim Thomas and Ms. Raisa De La Rosa
Date form was submitted*

YearMonthDay
Date
Have you met with the appropriate representatives prior to submission of this Extended Leave of Absence Request?*

YesNo
Please provide an approximate date of the discussions/meetings

MonthDayYear
Date
Are you a current Dual Degree Learner (both DO and MPH)?*

Yes (I am currently enrolled in both the DO and MPH programs)No (Currently, I am only enrolled in the DO program)
Dual degree learners taking a LOA from DO and MPH must submit two (2) seperate absence requests - one for DO and one for MPH.
Which Program is this Leave of Absence Request For?*

DOMPH
Type of Leave of Absence*

AdministrativeEducationalMedical
Administrative Leave of Absence - An administrative leave of absence may not exceed 180 days. Reasons for an Administrative Leave of Absence include but are not limited to:
• Death of a spouse, partner, child or immediate family member.
• Critical illness of a spouse, partner, child or immediate family member.
• Significant life events that warrant an interruption in the student's education.
• Activities or programs required by OME, OCA or SPC.

If the leave of absence exceeds 180 days within a 12-month period, the leave of absence may convert into and be deemed a withdrawal from the program. A student who is withdrawn under these circumstances must apply for readmission. The decision to readmit shall be made by the SPC with the approval of the Dean and appropriate administrators from the OSA. Factors relevant to readmission may include the student’s academic status, the nature, and duration of the leave of absence, demonstrated academic progress or personal growth during the leave of absence, and commitment to completing the remaining program of study.

When a student returns from a leave of absence, the student may be required to repeat or audit units or rotations that the student had previously completed. The SPC, in consultation with the ACC, shall determine the student’s appropriate academic placement and requirements for return.
Educational Leave of Absence - When accepted to a dual degree academic program (such as DO/MBA, DO/MPH) or in a structured research program that has prior approval by UIWSOM administration, the student may be placed on an approved Educational Leave of Absence from the DO program to complete the dual degree program. An Educational Leave of Absence is generally limited to one year.
Medical Leave of Absence - When a medical condition requires an absence that extends beyond 21 consecutive days for Phase I or 5 consecutive days for Phase II, the following applies:
• The student must provide the appropriate medical documentation, including but not limited to, a letter from the treating physician stating the nature of the medical condition and reasons it requires a leave of absence.
• The student may be required to provide additional information from the treating physician to determine the appropriate timeframe for return.
Clarification or substantiation for the medical leave of absence may be required if the medical leave is not common for the medical condition, to confirm that a medical condition exists, or if a second opinion from a physician is warranted.

For a student who receives an approved medical leave of absence and is in good standing at the time of the medical leave of absence, the SPC will recommend the student’s academic placement and other requirements for return if the medical leave does not exceed 180 cumulative days within a 12-month period.

If the medical leave of absence exceeds a total of 180 days in any 12-month period, the student is required to apply for readmission.

If the student was in good standing at the time of the requested medical leave of absence, they are eligible for readmission for the next academic year.
• The student must be approved for readmission by the SPC, which determines the academic placement of the student.
o The return may require repeating or auditing of units or clinical rotations already
taken.

A student who is applying to return from a medical leave of absence must provide documentation from the treating physician that (a) the student is eligible to fully participate in the medical school program and (b) the student meets the technical standards for enrollment at UIWSOM. The Dean and/or the SPC may require the student to obtain a second opinion from a physician at their cost.

A student who does not comply with the requirements for the medical leave of absence will be dismissed.
Last Date of Attending a Unit/Rotation/Course*

MonthDayYear
Date

Upload supporting documentation, if applicable

Cancelof

*A student who is absent for more than three days without approval shall meet with the Office of Student Affairs and may be referred to the SPC to address the student's absenteeism.

I acknowledge that I have reviewed the attendance policies outlined in the University of the Incarnate Word School of Osteopathic Medicine's Student Handbook.

By clicking "Submit" I am signing this form electronically. I agree my electronic signature is the equivolent of my manual signature on this form.
Should be Empty:

UIWSOM Absence Request

Extended Absence Request

Absence Related to Maternity

Leave of Absence Request