Request a Leave of Absence, Penn Engineering Graduate Student
This form must be completed to request a graduate leave of absence. 
  • For full information, conditions, and procedures for a leave of absence, please consult the student handbook: https://grad.seas.upenn.edu/student-handbook/academic-options/.
  • If you are an accelerated master's/submatriculant and you have not graduated from your undergraduate program (i.e. still enrolled as an undergraduate student at Penn) you will also need to complete the Undergraduate Leave of Absence request.
  • Students taking Medical Leave: Please ask your healthcare provider to fax documentation to 215-746-1032, Student Health and Counseling, Attention: Request Leave of Absence.  Do not provide medical documentation to faculty or staff in your program/department.
  • If requesting Family Leave, do not complete this form and go  here.
Email *
Surname/last/family name:
 *
Given/First Name:
 *
Preferred name (if applicable):
Penn ID (PID) number:
 *
Please list a personal email address (not upenn email) while on leave: *
Telephone number you can be reached: *
Degree Level: *
If you are a PhD student, please list the name of your faculty advisor(s):
Department/Program:
 *
Are you a Dual Degree Student?
*
If a Dual Degree student, please indicate the name of the other school/program:
Are you a Penn submatriculant/Accelerated Master's student?
*
I am requesting a Leave to start for the following semester (i.e. Fall, Spring, or Summer):  *
Please indicate the YEAR you are starting the leave: *
Please indicate the last date you attended classes in the current semester. 
(If your leave request is for the next semester, please use the last day of classes in the current semester.) *
Reason for the leave of absence?
*
If you are a PhD student taking a medical leave, and if SEAS currently covers your Penn Student Health Insurance, would you like the School to continue covering PSIP for one semester while you are on medical leave?
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What semester and year are you planning to return? (An estimate is fine.)
 *
By submitting this form, I confirm that all information is truthful and accurate to the best of my ability and all responses have been completed by myself.  Additionally, I give permission for the information submitted to be evaluated and processed by Penn Engineering staff. *
A copy of your responses will be emailed to .
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