"Other Academic Appointees (Oaa) Short-Term Disability Leave Form for Illness or Short-Term Disability Other Than Pregnancy - University of Chicago"

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Effective 11/11/2010
Questions about this form? Contact Ingrid Gould
E-mail:
igould@uchicago.edu
Other Academic Appointees (OAA) Short-Term Disability Leave Form
for illness or short-term disability other than pregnancy
Name ________________________________________________________
Date ___________________________
Home Address_________________________________________________ Department/School __________________
City, State, Zip__________________________________________________ Chicago ID________________________
Title ____________________________ Appointment begin & end dates _____________________________________
Other Academic Appointees who are benefits-eligible are eligible for short-term disability leave in accord with the OAA
Short-term Disability Leave policy. Pregnancy is covered under the OAA Maternity Leave policy, and Workers’
Compensation is covered under the Workers’ Compensation program. Short-Term Disability Leave counts toward leave
under the Family and Medical Leave Act (FMLA). Appointees must hold a current appointment and be in residence in
order to be eligible for short-term disability leave.
Two-week Period (includes 10 work days, including holidays): Unit pays full salary as usual. Employee benefits continue
shared as usual.
Date of 1st day of short-term disability leave: ____________________________
Date of 14th day of short-term disability leave: ____________________________
th
Eleven-week Period (begins on 15
day of consecutive absence): The University Benefits Office pays 60% of base
salary. Employee benefits are maintained with retirement contributions based on the adjusted 60% base salary.
th
Date of 15
day of short-term disability leave: _______________________________
Date of expected end of short-term disability leave: ___________________________
Short-term disability leave and its salary and benefits cease at the end of 13 weeks. For OAA who receive a term
allowance and/or administrative supplement, those salary components automatically terminate on day 30 of the 13-week
STD period.
If an appointee needs more than 13 weeks of leave, the limit of short-term disability leave, s/he must apply for long-term
disability leave by first contacting his/her Department Chair and/or Dean.
If there is to be a period of time between cessation of short-term disability leave and the beginning of long-term disability
leave and the appointment is current, then the appointee may request in writing an unpaid personal leave of absence,
which must be approved in advance in writing by the Department Chair and/or Dean and by the Office of the Provost.
__________________________________________________
___________________________
Signature
Date
__________________________________________________
____________________________
Department Chair or Representative
Date
__________________________________________________
____________________________
Dean or Representative
Date
Approved: ________
Denied: ________
________________________________________________
For Provost’s Office
Date
Effective 11/11/2010
Questions about this form? Contact Ingrid Gould
E-mail:
igould@uchicago.edu
Other Academic Appointees (OAA) Short-Term Disability Leave Form
for illness or short-term disability other than pregnancy
Name ________________________________________________________
Date ___________________________
Home Address_________________________________________________ Department/School __________________
City, State, Zip__________________________________________________ Chicago ID________________________
Title ____________________________ Appointment begin & end dates _____________________________________
Other Academic Appointees who are benefits-eligible are eligible for short-term disability leave in accord with the OAA
Short-term Disability Leave policy. Pregnancy is covered under the OAA Maternity Leave policy, and Workers’
Compensation is covered under the Workers’ Compensation program. Short-Term Disability Leave counts toward leave
under the Family and Medical Leave Act (FMLA). Appointees must hold a current appointment and be in residence in
order to be eligible for short-term disability leave.
Two-week Period (includes 10 work days, including holidays): Unit pays full salary as usual. Employee benefits continue
shared as usual.
Date of 1st day of short-term disability leave: ____________________________
Date of 14th day of short-term disability leave: ____________________________
th
Eleven-week Period (begins on 15
day of consecutive absence): The University Benefits Office pays 60% of base
salary. Employee benefits are maintained with retirement contributions based on the adjusted 60% base salary.
th
Date of 15
day of short-term disability leave: _______________________________
Date of expected end of short-term disability leave: ___________________________
Short-term disability leave and its salary and benefits cease at the end of 13 weeks. For OAA who receive a term
allowance and/or administrative supplement, those salary components automatically terminate on day 30 of the 13-week
STD period.
If an appointee needs more than 13 weeks of leave, the limit of short-term disability leave, s/he must apply for long-term
disability leave by first contacting his/her Department Chair and/or Dean.
If there is to be a period of time between cessation of short-term disability leave and the beginning of long-term disability
leave and the appointment is current, then the appointee may request in writing an unpaid personal leave of absence,
which must be approved in advance in writing by the Department Chair and/or Dean and by the Office of the Provost.
__________________________________________________
___________________________
Signature
Date
__________________________________________________
____________________________
Department Chair or Representative
Date
__________________________________________________
____________________________
Dean or Representative
Date
Approved: ________
Denied: ________
________________________________________________
For Provost’s Office
Date