Return from Leave of Absence Form

First Name*

Middle Name

Last Name*

Penn ID*

Email Address*

Phone Number

Degree*

Program*

Other/Dual Degree

Advisor First Name*

Advisor Last Name*

Term when leave began*

Year*

Return term as per your official letter*

Desired Return term*

Year*

Updated expected graduation term*

Year*

What type of leave was granted?*

Type of Medical Leave*

Have you submitted the Return from Leave form to Counseling and Psychological Services?*

You are required to submit the Return from Leave form to CAPS before GSE can process this request.

I understand that I am required to submit the appropriate documentation to Counseling and Psychological Services at this time.*

Have you submitted the Return from Leave form to Student Health Services?*

You are required to submit the Return from Leave form to SHS before GSE can process this request.

I understand that I am required to submit the appropriate documentation to Student Health Services at this time.*