Fall 2023 Time Away Inquiry Form

This form is used to collect information regarding your interest/need in taking a time away from Duke. The Time Away Office will follow up with each student individually regarding your time away request and help you develop a time away plan. Once your leave has been processed, you will get a formal time away letter with information regarding time away policies, return process and return timelines. If you have any questions, please feel free to reach out by emailing timeaway@duke.edu and Kimberly Blackshear will follow up with you.

Please provide your name First Name and Last Name as it appears in DukeHub.

If you have a preferred name please include it in quotes.

James "Jimmy" Smith or Elizabeth "Lizzy" Jackson

Pronouns*

The is a 7-digit number that typically starts with a 2.

Please select the class that best describes you.

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Type of Leave*

If you are not sure what leave type best fits your needs, you can reach out to the Time Away Office and we can discuss it. If you select something that may not bee the best fit, we can make that change during the time away process.


Time Away Definitions

Personal Leave planned leave that happens BEFORE the semester starts


Medical Leave happens during the course of a semester where an unexpected medical situations impacts your education that requires you to put a pause in your education to keep medical treatment.


Discontinuation/Transfer means your are planning to transfer to another school and/or you do not plan to return Duke


Voluntary Withdrawal means you want to take a time away and have the opportunity to return (are not transferring to another school); it is important to note that based on when you take a voluntary withdrawal can have major impact on final grades (use link above for more information)


Special Completion means that you have already met all graduation requirements and plan to return to participate in graduation activities.

Readiness*
Medical Leave Additional Inform*


Additional Medical Leave Information

If requesting a Medical Leave of Absence, your Time Away Inquiry form is not complete until your treatment provider completes the Provider Recommendation for Treatment Form. The Time Away Office will send you a copy of the form when your Time Away Inquiry form is received. Once your provider has completed the Provider Recommendation for Treatment Form, they can email the form directly to the Time Away Office email address: timeaway@duke.edu or fax the completed form to the Time Away Office at (919) 668-6393. At that point, the Time Away Office will schedule a meeting with you to review the treatment recommendations and develop a time away plan.


Please confirm that you received these medical leave instructions.

The date you are completing this form

Academic School*
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Please identify how you would to communicate with the Time Away Office during your leave.

Please provide your phone number (XXX) XXX-XXXX. If you have an international number, please provide the correct country code.

This number WILL NOT be shared with others outside the Time Away Office and will be used to send reminders about return timelines.

Please provide your personal email

J1 F1*

Are you a J1/F1 visa holding student?

Continue Health Insurance*
Housing*

Do you currently live in university owned housing?

Please select the dorm you are currently residing

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Time Away Location*

Where do you plan to be during your time away?

"Home" refers to the address listed in DukeHub as your permanent address.

Where do you plan to be during your time away? (please provide the address if possible or the general location if the address has not be established--like 1555 West Hall Street, Apt 112, Castadia, Florida 55555 or 64 Rue du Ranelagh, 75016 Paris, France)

What is the date that you plan to move out?


Housing Policy: Generally, when students residing on campus request a time away of any kind, they are provided 72 hours to move off of campus. The Time Away Office can help with develop a move out plan (the 72 hour policy does NOT start when you complete this form, we will meet to develop a move out plan together).


Plans to Work or Intern*

Do you plan to work or do an internship/fellowship during any part of your time away?

Research*

Do you plan to be a part of your research during any part of your time away?

Please provide the name of your employment/internship/research site.

We DO NOT plan to contact them in any way. We are trying to understand where students are working and opportunities during your time away.


Please let use know if you program or research is at Duke so we can work through DukeCard access during your time away

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Please list the name of your scholarship

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Please share your reason for requesting to take a leave of absence.


What prompted your decision to take a leave of absence?


How will you spend your time away (e.g., where you will be living, your local support network, any goals you wish to accomplish while away)?


What kind of local support/resources do you have to help you accomplish your goals while away?


How can the Time Away Office, your academic dean, DukeReach and other offices support you while you are away?

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