Modified Duties for Childcare (MDC) Program

Request for Approval Form
(complete prior to start of semester)

Fill out this simple online form prior to the start of the semester for which teaching and committee service exemption is sought. Please provide as much notice as possible, as it can be difficult to identify a qualified individual to cover the teaching assignment in a short period of time. Based on the form, the School/Division head will approve one semester off teaching and committee work (either for the semester immediately following or for the semester concurrent with the childbirth/adoption event) based on School/Division needs and after consultation with the Senior Associate Dean of the Faculty.

First Name*
Last Name*
School of Primary appointment*
School/Division of joint appointment
Nature of expected event*
Expected year of event*
Likely month of event*
If yes, which weeks are planned to be covered by FMLA/PPL?
Will you be the primary caregiver of the child for the semester off requested for Modified Duty for Childcare (MDC)? The primary caregiver is a parent who takes significant and sustained caregiving responsibility during the period for which the one semester of MDC is requested, as defined by at least 20 hours of primary caregiving during the typical Monday-Friday 9 a.m. to 5 p.m. workweek.*
Which semester off do you request for MDC?*