Full Name:
ID:
Application for a Leave of Absence
Postgraduate Researchers
Registry, Academic Services
PART A: To be completed by the PGR (insert your ID No. and name on each page of this form)
Surname (Family Name)
Forename(s)
Title
Dr, Mr, Ms, Mrs
Student ID Number
School/Department
Degree/Mode of Study (eg PhD, FT)
Date of entry into this programme of study
Name(s) of Supervisor(s)
If you have held/or hold a Research Council award please indicate below which one
AHRC
Approval of the Research Council will be obtained by the Research Council Studentship Officer
EPSRC/MRC
Prior approval of EPSRC/MRC not required.
BBSRC/STFC/NERC
Approval of the Research Council will be obtained by the Research Council Studentship Officer
ESRC
Approval of the Research Council will be obtained by the Research Council Studentship Officer
1.
Have you taken a previous Leave of Absence? Yes
No
If yes, please give details, including dates and brief reasons (i.e. medical, financial, etc)
2.
Dates of new Leave of Absence requested
From:
3.
To:
Reasons for requesting a Leave of Absence
Medical
Financial
Compassionate/bereavement
Competitive Sports
Personal
Major unforeseen disruption
Other (state reason)
July 2015
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Full Name:
4.
ID:
Please state your reasons for requesting a Leave of Absence (max 500 words)
For retrospective requests please state why you were unable to apply at the appropriate time.
5.
Supporting evidence attached (e.g. medical certificate, financial evidence)?
Yes
No
You should be aware that these documents may be made available to the University’s Research Progress & Awards Sub
Panel.
If you are unable to provide supporting evidence, please explain why:
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Full Name:
6.
ID:
International postgraduate researchers
If you are an international student and in the UK on a student visa, your right to remain in the UK will be affected by a
temporary withdrawal from study. During a period of Leave of Absence your student registration status changes and to
meet the conditions of the University’s Tier 4 Sponsor License, we are required to report any changes in registration status
to the Home Office.
You are strongly advised to discuss your Leave of Absence request with the International Student Advisory Service (ISAS)
prior to submitting your request, so you can be informed of the actual implications to your visa. You can contact ISAS by
telephone on 0121 414 8464 or online at: www.studenthelp.bham.ac.uk.
Should you decide not to take immigration advice from this specialist service, please be advised that you do so entirely at
your own risk.
6.1 Do you currently hold a UK Visa?
Yes
No
If yes, please indicate the type of visa you hold (i.e. Tier 4, Dependant): …………………………..
6.2 Visa Expiry Date:
6.3 Do you currently hold Indefinite Leave of Remain of Refugee status
Yes
No
6.4 Are you currently in the UK?
Yes
No
Only answer question 6.5 if you are taking Leave of Absence for maternity or if you are taking a medical Leave of
Absence for 8 weeks or less
6.5 Are you planning to remain in the UK during your Leave of Absence
Yes
No
Please attach a photocopy of your current passport photo page and visa. If you extended your visa in the UK you will have
a pink biometric residence permit – please submit a copy of both sides of this card. Your extension request will not be
processed unless these supporting documents are received.
Passport copy attached
Visa/biometric residence permit copy attached
7.
Do you live in University owned accommodation?
Yes
July 2015
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Full Name:
8.
ID:
Contact address
It is your responsibility to ensure that you keep the University updated with your address details and you can update
these at any time via the on line registration facility at www.my.bham.ac.uk. Please confirm where you are currently
residing (address, post code, telephone number):
Address
From (date)
9.
To (date)
E-mail address
Please confirm the e-mail address you wish the outcome of your request to be sent to:
10. Declaration
I understand the implications of taking a Leave of Absence from my studies and that it is my responsibility to notify the
Research Student Administration team of my wish return to my study at the end of the Leave of Absence requested on
this form.
Signed:
Date:
Please forward to your supervisor for completion of PART B.
PART B: To be completed by the Student’s Lead Supervisor
1.
I do/do not* support this request (*Delete as appropriate).
Please give your rationale for your response (whether supporting the student’s request or not). Requests will be returned
if this information is not included.
2.
Is evidence to support this request attached?
Yes
No
If you are supporting the application without evidence, please state the reasons for this below.
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Full Name:
3.
ID:
For PGRs holding a Tier 4 visa, attendance records must be checked and attached to the form.
Attendance records attached?
Yes
No
Please comment on any instances where the leave of absence dates conflict with the attendance records.
Signed:
Date:
Name (Block capitals):
PART C: To be completed by the Head of School (or School Director of PGR Studies). Where the Head of School (or
nominee) is the student’s supervisor, an alternative person of equal standing should complete Part C.
1.
I do/do not* support this request (*Delete as appropriate).
Please give your rationale for your response (whether supporting the student’s request or not). Requests will be returned
if this information is not included.
Signed:
Date:
Name (Block capitals):
Please forward the completed form, together with supporting documents, to Lyn Hipwood, Assistant Manager,
Research Student Administration, Registry, Academic Services
PART D: To be completed by the University’s Research Progress & Awards Sub Panel and returned to Lyn Hipwood,
Assistant Manager, Research Student Administration, Registry, Academic Services.
1.
On behalf of the University’s Research Progress & Awards Sub Panel, I do/do not* approve the request for an
extension (*delete as appropriate).
Please give the rationale for your decision:
Signature:
Date:
Name (Block capitals):
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Full Name:
ID:
FOR OFFICE USE
If RC funded, Finance Office/Studentship Adviser notified
Previous LoA:
Min Date :
Previous
New
Max Date :
Fees: Refund/to pay
SHATCMT/SHANCRS
Billing Course
Visa Expiry Date
Attendance Monitoring checked
Y/N
Referred to ISAS
Y/N
Report to Home Office
Y/N
Disability Team
Y/N
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