Medical Leave of Absence Forms

Here you will find links to all of the forms that are required to apply for a Medical Leave of Absence, and to request to return from a Medical Leave of Absence. To request an extension, please visit our Medical Leave of Absence Extension page.

Please note: Requests will not be reviewed without all of the required components having been submitted. However, if you run into any questions or barriers while completing the process please reach out to the Dean of Students for assistance

Any undergraduate requesting reinstatement and requires on-campus housing must send a Notice of Intent to Be Reinstated with On-Campus Housing Form no later than:

Fall semester – May 31
Spring semester – November 1
Summer semester – April 1

All students must submit a Request for Reinstatement Form by the deadlines below:

Fall semester – June 30
Spring semester – November 1
Summer semester – April 1

A view through the front gates of Georgetown University, with Jack the Bulldog sitting in front

Forms to Request an MLOA

Medical Leave of Absence Request Form – This is an online form that cannot be saved or edited after submission. Please be prepared to complete it in one session.

MLOA Additional Documentation Submission Form – The purpose of this form is to provide an additional method for submitting documentation to support your request for a medical leave of absence if you don’t have your documentation available at the time of your initial request.

Provider MLOA Recommendation Form – This is a fillable PDF that should be shared with your treating healthcare provider who may be a CAPS, Student Health Services, or a non-GU provider.

Provider Secure Documentation Submission Form – This form provides a secure method for healthcare providers to submit medical documentation and recommendations to the Dean of Students. Please do not submit confidential medical information by email.

Release of Information – This is a fillable PDF that will allow the Dean of Students and/or Student Outreach and Support to speak with your healthcare provider in the event more information is needed to review your MLOA Request.

Forms to Request Reinstatement from MLOA

Notice of Intent to be Reinstated with On-Campus Housing – This form is for Undergraduate Students Only and is not a replacement for the traditional housing request process. If you need to request Housing Accommodations please contact the ARC.

Medical Leave of Absence Reinstatement Request Form – This is an online form that cannot be saved or edited after submission. Please be prepared to complete it in one session. You will be required to provide a personal statement that addresses the following:

How you used the MLOA to address your healthcare needs.
Your plan to be successful upon return to the University
Any additional information that you would like considered in regards to returning to the University.

MLOA Additional Documentation Submission Form – The purpose of this form is to provide an additional method for submitting documentation to support your request for reinstatement medical leave of absence if you don’t have your documentation available at the time of your initial request.

Provider Reinstatement Recommendation Form – This is a fillable PDF that should be shared with your treating healthcare provider who may be a CAPS, Student Health Services, or a non-GU provider.