MEDICAL LEAVE OF ABSENCE PACKET - pace.edu€¦ · 01/09/2012  · resulted in a recovery period longer than was anticipated at the time the student applied for a medical leave of

MEDICAL LEAVE OF ABSENCE PACKET

Table of Contents

1. Medical Leave of Absence Policy …………………………………………………….. Page 2 2. Medical Leave of Absence Application ………………………………………………. Page 5 3. Authorization for Information Release for the Use and Disclosure of PHI ……….. Page 7 4. Consent for Communication Regarding Request for MLOA or ROS …………….. Page 9 5. Registration Action Request …………………………………………………….......... Page 10 6. FERPA Authorization Form ……...……………………………………………………. Page 12

MEDICAL LEAVE OF ABSENCE POLICY

Students sometimes find it necessary or desirable to interrupt their enrollment at Pace University

due to their own serious medical condition. A leave of absence pursuant to this Medical Leave of

Absence Policy may commence during a semester or prior to the beginning of a semester and

ordinarily is limited to two consecutive semesters, excluding summer semesters. A student, who

is unable to complete the semester and applies for a leave of absence, must also withdraw from

the courses in which he or she currently is enrolled and will receive a “W” for each course from

which the student withdrew. Although the “W” grades will appear on the student’s transcript,

they will not affect the student’s cumulative quality grade point average. In addition, the student

will be subject to the Tuition Cancelation Policy and certain financial aid rules and procedures.

(Further information about the impact of a medical leave of absence on a student’s financial aid

may be found below under Financial Aid.)

Procedure. Students contemplating a medical leave of absence due to their own serious medical

condition should contact the Office of Student Assistance to discuss the procedure and obtain the

necessary forms. Students are encouraged to speak with their academic advisor prior to

submitting a Medical Leave of Absence Application. Academic advisors can provide

information about the effect of a medical leave of absence on such issues as course sequencing

and graduation date.

In order to apply for a medical leave of absence, a student must complete a Medical Leave of

Absence Application, a Consent for Communication Regarding Request for a Medical Leave of

Absence and/or Resumption of Studies after a Medical Leave of Absence, and an Authorization

for Information Release. The completed Application, Consent and Authorization must be

submitted to the University Registrar, Office of Student Assistance, 156 William Street, 5th Floor, New York, NY 10038. Upon receipt of these documents, the University Registrar will send a

copy of the Authorization and a Treating Healthcare Provider’s form to the student’s treating

healthcare provider in order to obtain information about the condition necessitating a medical

leave of absence.

The completed Treating Healthcare Provider’s form is to be returned by the treating healthcare

provider to the Counseling Center or University Health Care, as the case may be, for review. If

the Counseling Center or University Health Care approves the application for a medical leave of

absence, the University Registrar will assist in obtaining the other necessary approvals.

Students are required to provide whatever additional information and/or documentation the

University may require concerning the student’s request for a medical leave of absence.

Packet Date: 4/2019 Form Add Date: 4/2019Page 2

Upon returning from a medical leave of absence, the student must complete a Resumption of

Study after a Medical Leave of Absence Application. Information about resuming studies may

be found in the letter granting approval of the medical leave of absence and the Resumption of

Study Policy, and from the University Registrar.

Length of a Leave of Absence. Ordinarily, a leave of absence pursuant to this Medical Leave of

Absence Policy is limited to two consecutive semesters excluding the summer semesters and may

be commenced at any time. For purposes of counting the two consecutive semesters, a leave of

absence shall commence at the beginning of the first fall or spring semester after the student

applies for and approval is granted for a leave of absence.

Under certain circumstances, however, a leave of absence due to a student’s serious medical

condition may be extended for a total of four consecutive semesters (excluding summer

semesters). For example, a student may have experienced post-operative complications that

resulted in a recovery period longer than was anticipated at the time the student applied for a

medical leave of absence. Under such circumstances, and following the same procedure set forth

above, the student may request an extension of the medical leave of absence. In order to be

eligible for an extension, the student must provide whatever documentation the University may

require concerning the reason for the extension. A leave of absence due to a student’s serious

medical condition will not be approved for more than a total of four consecutive semesters

(excluding summer semesters).

Degree Requirements and Graduation Date. Ordinarily, the degree requirements applicable to

the student’s declared major will not change due to the student’s medical leave of absence.

Nevertheless, there are circumstances when the degree requirements or program offerings will

change while the student is on a medical leave of absence, e.g., requirements of the New York

State Education Department, accrediting agencies or applicable law.

The time within which a student is required to complete the degree requirements ordinarily will

not change because of a medical leave of absence, although the graduation date may change. For

example, a student who is required to complete the degree requirements within eight semesters is

scheduled to graduate in May 2012 takes a medical leave of absence in the spring 2011 semester.

Because of the one-semester absence, the student’s graduation date may be postponed one

semester until December 2012 at which time he or she will have been enrolled for eight

semesters. However, a student’s graduation date may be postponed in excess of the number of

semesters he or she was on a medical leave of absence if the student is enrolled in a program

with required course sequences and the prerequisite courses are not offered every semester.

Students should check with their academic advisor before applying for a Medical Leave of

Absence and again when resuming their studies about the consequences, if any, of their leave of

absence on degree requirements and graduation date.

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Transfer of Credits Earned During Medical Leave of Absence. Students contemplating taking

courses at another college or university during their medical leave of absence and transferring

those course credits to Pace University upon their resumption of studies should consult with their

academic advisor before enrolling in courses elsewhere. Transfer credits for such courses must

be approved in advance by Pace University; otherwise, they may not be accepted by the

University.

Financial Aid. Students on a leave of absence pursuant to this Medical Leave of Absence Policy

are considered to be withdrawn from the University for purposes of financial aid. Consequently,

loan repayment obligations may be triggered. Students should speak to a representative of the

Financial Aid Office for more detailed information about the status of their financial aid during a

leave of absence prior to submitting a Medical Leave of Absence Application.

Ordinarily, Pace-funded merit awards will be restored upon a student’s resumption of studies

after a leave of absence in accordance with this Medical Leave of Absence Policy provided (i) all

other requirements for such merit aid are satisfied, and (ii) the student resumes his or her studies

by the date identified and approved in the Medical Leave of Absence Application. If a student

does not resume his or her studies on or before the date identified and approved in the Medical

Leave of Absence Application or obtain an extension of the leave of absence if the student is

eligible for one, Pace-funded merit awards may be excluded from future financial aid awards.

(Related information about the reinstatement of Pace-funded merit awards may be found in

Reinstatement of Pace-funded Merit Award Following a Medical Leave of Absence Policy.)

International Students. The University is legally obligated to report a leave of absence for any

reason by a student with an F-1 or J-1 visa to the Department of Homeland Security. Students

with an F-1 or J-1 visa who take a leave of absence may not remain in the United States during

the leave unless the reason for the leave is an illness that prevents the student from returning to

his or her home country and appropriate documentation from a hospital in the United States has

been provided.

Students with an F-1 or J-1 visa who are contemplating a leave of absence must first consult with

an advisor in the International Students and Scholars Office, and again when they resume their

studies after a leave of absence.

Effective September 1, 2012

Packet Date: 4/2019 Form Add Date: 4/2019Page 4

CREATED 08/12

OFFICE OF STUDENT ASSISTANCE MEDICAL LEAVE OF ABSENCE APPLICATION

_______________________________________________________________________________________________________________________________________ STUDENT ID NUMBER LAST NAME FIRST NAME MIDDLE

_______________________________________________________________________________________________________________________________________ STREET ADDRESS/P.O. BOX CITY STATE ZIP

_______________________________________________________________________________________________________________________________________ DAY TELEPHONE NUMBER EVENING TELEPHONE NUMBER MOBILE/CELL NUMBER E-MAIL ADDRESS

Semester the Medical Leave of Absence is to be effective: Semester the Resumption of Studies will occur: FALL (70) YR 20_____

SPRING (20) YR 20_____

I am currently enrolled as follows:

FALL (70) YR 20_____

SPRING (20) YR 20_____

LEVEL: HOME CAMPUS: DEGREE: ______________________________________ 01 (Undergraduate) 1 (New York City) 02 (Graduate) 2 (Pleasantville) MAJOR: ______________________________________ 05 (Doctoral) 3 (White Plains)

Full-time Day Part-time Evening

Along with this application, I have completed and attached the following forms:

CONSENT FOR COMMUNICATION REGARDING REQUEST FOR MEDICAL LEAVE OF ABSENCE AND/OR RESUMPTION OF STUDIES AFTER A MEDICAL LEAVE OF ABSENCE AUTHORIZATION FOR INFORMATION RELEASE FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I have read and understand the University’s Medical Leave of Absence Policy.

____________________________________________________________________ Student’s Signature Date

THE FOLLOWING IS TO BE COMPLETED BY THE UNIVERSITY REGISTRAR Verification of Documentation:

CONSENT FOR COMMUNICATION REGARDING REQUEST FOR MEDICAL LEAVE OF ABSENCE AND/OR RESUMPTION OF STUDIES AFTER A MEDICAL LEAVE OF ABSENCE AUTHORIZATION FOR INFORMATION RELEASE FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Sent: TREATING HEALTHCARE PROVIDER’S STATEMENT FOR MEDICAL LEAVE OF ABSENCE

Verification Received From: University Health Care NYC PLV Date ______________________

Counseling Center NYC PLV Date ______________________

Sent to: Academic Advisor Chairperson Assistant or Associate Dean

Packet Date: 4/2019 Form Add Date: 4/2019Page 5

• University Registrar, Office of Student Assistance, 156 William St., 5th Floor, New York, NY• University Registrar, Office of Student Assistance, Administrative Center, 861 Bedford Road, Pleasantville, NY 10570• [email protected]

Please see the University’s Medical Leave of Absence Policy for more information.

In order to apply for a medical leave of absence, a student must complete a Medical Leave of Absence Application, a Consent for Communication Regarding a Request for Medical Leave of Absence and/or Resumption of Studies after a Medical Leave of Absence, and an Authorization for Information Release. The completed documents must be submitted to either:

ACADEMIC APPROVAL

____________________________________________________________________________ Academic Advisor/Chair/Associate or Assistant Dean (Print) Office Phone Number

____________________________________________________________________________ Signature of School/College Official Date

FOR OFFICE OF STUDENT ASSISTANCE USE ONLY

□ WITHDRAWN FROM CURRENT SEMESTER AND/OR DROP FROM FUTURE SEMESTER

□ NOTIFIED TUITION APPEAL ABOUT POTENTIAL MEDICAL CANCELLATION

□ CREATE NEW SGASTDN RECORD

□ UPDATE STUDENT STATUS

□ UPDATE CURRICULA TAB (then SAVE)

□ NOTIFIED CAMPUS DIRECTOR/ASSOCIATE DIRECTOR OF FINANCIAL AID BY EMAIL (IF PACE MERIT BASED AID RECEIVED)

□ SENT APPROVAL LETTER

□ SENT CONSENT FOR COMMUNICATIONS

□ SENT AUTHORIZATION FOR INFORMATION RELEASE

□ SENT RESUMPTION OF STUDIES AFTER A MEDICAL LEAVE OF ABSENCE APPLICATION

□ SCAN INTO BDMS AND FILE ORIGINAL

□ PROCESSED BY ______________________________________________ DATE _______________ OSA REPRESENTATIVE

Packet Date: 4/2019 Form Add Date: 4/2019Page 6

AUTHORIZATION FOR INFORMATION RELEASE

FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I, , the undersigned, authorize the use and/or disclosure of my Protected Health Information (“PHI”) as described below. I understand that my treatment, payment, enrollment in benefits or eligibility for benefits will not be conditioned on the signing of this authorization.

□ HIV-related Information: Check here if this authorization is for HIV-related information. If so, in additionto completing this form, please complete a New York State Department of Health mandated Authorization forthe Release of Confidential HIV-Related Information.

1. Patient Information

Name: Date of Birth: Address:City: State: _________________ Zip:

2. Person(s) Authorized to Disclose PHI:

Name:Address:City: State: Zip:Phone:____________________________________ Fax: _______________________________________

3. Person(s) Authorized to Receive PHI: (check applicable persons)

_____ Audrey Hoover, Director _____ Dr. Richard Shadick, Director University Health Care Counseling Center 1 Pace Plaza, 6th Floor East 156 William Street, 8th Floor New York, NY 10038 New York, NY 10038

_____ Karen Martin, Associate Director _____ Dr. Rosa Ament, Director University Health Care Counseling Center Paton House, Ground Floor Administration Center, 2nd Floor 861 Bedford Avenue 861 Bedford Road Pleasantville, NY 10570 Pleasantville, NY 10570

4. Description of PHI to be Disclosed:

_____ Diagnosis _____ Summary of treatment

_____ Diagnostic code _____ Treatment recommendations

_____ Symptoms _____ Current clinical status

_____ Other (describe directly below)

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Packet Date: 4/2019 Form Add Date: 4/2019Page 7

____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

5. Reason for Disclosure: Please indicate the reason for the disclosure of the above stated PHI:

_____ Request for medical leave of absence from Pace University

_____ Request to resume studies at Pace University after a medical leave of absence

6. Expiration Date/Event: This authorization will expire upon the date a final decision is made with to respectto my resumption of studies at Pace University unless it is revoked earlier in a writing sent to Office of StudentAssistance, Pace University at: 156 William Street, New York, NY or Administrative Center, Pleasantville, NY10570.

This authorization shall become effective immediately. I understand that I have the right to revoke this authorization in writing at any time, except to the extent that it has already been relied upon. I understand that in order to revoke this authorization my revocation must be submitted in writing to the University Registrar, Office of Student Assistance. I further understand that when my PHI is disclosed pursuant to this authorization it may be subject to redisclosure by the person(s) authorized to receive my PHI.

Dated: 20 Signature of Patient or Personal Representative

Description of Personal Representative’s Authority

Packet Date: 4/2019 Form Add Date: 4/2019Page 8

Printed Name of Patient or Personal Representative

This completed and signed form should be returned to:

Office of Student Assistance 156 William Street, 5th Floor New York, NY 10038 [email protected]

or

Office of Student Assistance Administrative Center 861 Bedford Road Pleasantville, NY 10570 [email protected]

CONSENT FOR COMMUNICATION REGARDING REQUEST FOR

MEDICAL LEAVE OF ABSENCE AND/OR RESUMPTION OF STUDIES

AFTER A MEDICAL LEAVE OF ABSENCE

, provide permission for the (check one orI,

both, as applicable)

_____ Counseling Center

_____ University Health Care

to communicate only as necessary with the Office of Student Assistance, Dean for Students Office, the

Office of Residential Life, my Academic Advisor and Department Chair, and other University administrators

for the purpose of providing recommendations pertaining to my request for a medical leave of absence and/or

request to resume my studies at Pace University.

I understand that these communications may include, only as necessary, information the Counseling Center

or University Health Care, as the case may be, has created, received or maintains concerning me. I

understand that these communications may include information concerning the physical health or mental

health condition(s) which necessitated my medical leave of absence.

This Consent applies only to my request for a medical leave of absence and any request to resume my studies

after a medical leave of absence. Unless revoked earlier, this Consent will expire after Pace University

makes a final decision concerning my resumption of studies.

I understand that I may revoke this Consent at any time by notifying the University Registrar, Office of

Student Assistance, in writing of my revocation except to the extent that Pace University has taken actions in

reliance on it. I understand that this Consent is essential to Pace University’s medical leave of absence and

resumption of studies process, and, if I fail to sign this Consent or revoke it before a decision has been made

concerning my request for a medical leave of absence or resumption of studies, my request for a medical

leave of absence or resumption of studies, as may be the case, may be denied.

Student Signature:

Date:

Witness Signature:

Date:

This completed and signed form should be returned to:

Office of Student Assistance - University Registrar

156 William Street, 5th Floor, New York, NY 10038

or

Office of Student Assistance - University Registrar Administrative Center861 Bedford Road, Pleasantville, NY 10570

[email protected]

Packet Date: 4/2019 Form Add Date: 4/2019Page 9

OFFICE OF STUDENT ASSISTANCE

REGISTRATION ACTION FORM

PLEASE RETURN TO THE OFFICE OF STUDENT ASSISTANCE (OSA). ANY QUESTIONS CALL 1 (877) 672-1830. UNIVERSITY

STUDENT ID NUMBER LAST NAME

If this is a new address/phone#, please indicate what you would like to be updated on your record

STREET ADDRESS/P.O. BOX

DAV TELEPHONE NUMBER

HOME

CAMP US: 0 New York (1)

□Westchester (2)0 White Plains {3}

CITY

EVENINGTELEPHONE NUMBER

LEVEL:

□Undergraduate (01)

□Graduate (02)

0 Law {03}

O Doctoral (OS)

0 Law - LL M (06)

0 Law - SJD (09)

FIRST NAME

D Address D Telephone

STATE

MOBILE/CELL NUMBER

SEMESTER:

0 SPRING (2) 0 FALL (7)

0 OTHER

MIDDLE

ZIP CODE

□SU MMER 1 (4)□SU MMER 2 (S)

YEAR: __ _

E MAIL ADDRESS

Have you submitted a graduation

diploma verification form?

□YES □NO

PLEASE COMPLETE: IF YOU ARE MAKING A CHANGE TO YOUR ORIGINAL REGISTRATION, PLEASE STATE THE REASON FOR CHANGE:

(Changes to your credit load may have an impact on Financial Aid, Health Insurance, etc.) All approval signatures MUST be entered on second page.

SECTION A- COURSE(S) TO DROP/ WITHDRAW SECTION B - COURSE(S) TO REGISTER/ ADD

REG CODE I SUBJECT COURSE NO. COURSE CR. REFERENCE NO. REG CODE SUBJECT COURSE NO. COURSE CR.

REFERENCE NO. A C C 103 10603 3 A C C 104 10608 3

TOTAL CREDITS: TOTAL CREDITS:

I agree to be governed by the conditions that are prescribed in the current Pace Uriversity catalog (which I have had the opportunity to read) with respect to the registration of students, sc holarship, attendance, payment

or abatement of fees, and other policies relevant to Pace University students. To the best of my knowledge, I have answered all foregoing questions truthfu ll y and accurately.

STUDENT'S SIGNATURE DATE OSA SIGNATURE DATE

Updated 6/2015

Packet Date: 4/20 I 9 Form Add Date: 4/20 I 9 Page 10

REGISTRATION ACTION FORM - PERMISSION TO REGISTER FOR EXCEPTIONS

PLEASE RETURN TO THE OFFICE OF STUDENT ASSISTANCE (OSA). ANY QUESTIONS CALL 1 (877) 672-1830

U#: ------------------ Name: _________________ _ Degree/Major: _____________ _ Expected Graduation Date: __________ _

If you are requesting permission to register for exceptions (see list below), this form must be completed, along with the reverse side, and submitted to the appropriate dean, chairperson, or advisor for approval. Graduate students please refer to your school catalog

for academic policy regarding exceptions.

♦ CLOSED CLASS * f I you are currently reg1stere ora 1 erent section o t e c ose c ass, 1n 1cate-d f d'ff f h I d I please · d.

COURS'E SUBJECT COURSE "'CURRENTLY ACADEMIC APPROVAL/DATE REFERENCE NO. NO. REGISTERED C.R.N.

♦ OUT OF MAJOR COURSECOURSE SUBJECT COURSE *CURRENTLY ACADEMIC APPROVAL/DATE

REFERENCE ('JO. NO. REGISTERED C.R.N.

♦ OUT OF DIVISION COURSECOURSE SUBJECT COl:JRSE "CURRENTLY ACADEMIC APPROVAL/DATE

REFERENCE NO. NO. REGISTERED C.R.1\1.

♦ EXCEEDS MAXIMUM CREDIT HOURSTOTAL CREDITS APPROVED ACADEMIC APPROVAL/DATE

FOR CURRENT SEMESTER

♦ SOPHOMORE, JUNIOR OR SENIOR STANDING REQUIREDCOU-RSE SUBJECT COURSE "'CURRENTLY ACADEMIC APPROVAL/DATE

REFERENCE NO. NO. REGISTERED C.R.N.

♦ TIME CONFLICT (Please include both courses that are conflictl'lg)COURSE Sl!JBJECT COURSE *CUR'RENTLY INSTRUCTOR APPROVAL/ CHAIR APPROVAL/

REFEREN<ZE No: No. REGISTERED C.R.N. DATE DATE

♦ UNSCHEDULED COURSE (Tutorial)COURSE SUBJECT COURSE *CURRENTLY DEAN APPROVAL/ CHAIR APPROVAL/

REFERENCE NO. NO REGISTERED C.R.N, DATE DATE

♦ INSTRUCTOR OR CHAIRPERSON SIGNATURE REQUIRED ( ex. nterns 1ps, rave , e c h' I t J

COURSE SUBJECT COURSE •CURRENTLY INSTRUCTOR APPROVAL/ CHAIR APPRGVAL /

REFERENCE NO. NO REGISTERED C.R.N. DATE DATE

Updated 5/2015

Packet Date: 4/2019 Form Acid Date: 4/2019 Page 11

Last Updated 5/2011

AUTHORIZATION TO DISCLOSE INFORMATION FROM EDUCATION RECORDS

The Family Education Rights and Privacy Act generally prohibits Pace University from disclosing personally identifiable information from a student’s education records to a third party (including a student’s parents) without the student’s prior written authorization.

I hereby authorize Pace University to disclose the following information from my education records to the person identified below pursuant to the terms and conditions set forth below.

Information That May Be Disclosed (check one or more):

___ Academic information ___ Graduation information

___ Student account information ___ Financial aid information

___ Housing information ___ Disciplinary information

___ Other (specify) _____________________________________________________________________________

The Information May Be Disclosed To:

Name: _______________________________________________________ Telephone: ____________________________

Address: _____________________________________________________________________________________________

E-mail: ______________________________________________________________________________________________

The Information Is Being Disclosed For The Following Purpose (check one):

___ Family communications ___ Employment ___ Academic reference

___ Other (specify) _____________________________________________________________________________

The Information May Be Disclosed (check one):

___ Orally ___In writing ___Either or both

This Authorization Expires (check one):

___ On the last day of my enrollment as a Pace University student

___ On the date I provide a written revocation of this Authorization to Pace University

___ Other (specify)_____________________________________________________________________________

Authorization Code

Please create an authorization code in the space below. The authorization code may be letters, numbers, or a combination of both.

______________________ Authorization Code

You must give this authorization code to the individual identified above to whom you authorize disclosure. The authorization code and photo identification may be required before information is disclosed as permitted by this authorization form.

_______________________________________________________ ____________________________ Print Name of Student Student ID No.

_______________________________________________________ ____________________________ Signature of Student Date

Packet Date: 4/2019 Form Add Date: 4/2019

The following notice will be provided to the persons or entities identified above: The information disclosed to you is governed by the provisions of the Family Educational Rights and Privacy Act. 20 U.S.C. § 1232g. Therefore, the disclosed information may be used only for the purposes identified by the student and may not be redisclosed to others without the specific written authorization of the student.

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