Acknowledgement:* I am the student submitting the change in status request. I am a faculty or staff member submitting the change in status request on behalf of the student. Your name:* Student name:* First Last Date* MM slash DD slash YYYY RVU ID Number:* Program:* Doctor of Osteopathic Medicine (DO) Doctorate of Nurse Anesthesia Practice (DNAP) Master of Physician Assistant Studies (PA) Master of Science in Biomedical Sciences (MSBS) - Colorado and Utah only Master of Medical Sciences (MMS) - MCOM Additional Program Designations (check all that apply): Track Military Fellow What is the name of the Track and the Track Director? Which class?* OMS I OMS II OMS III OMS IV Campus:* Colorado Montana Utah Permanent mailing address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone number:Email address:* Type of change in status:* Leave of absence Complete withdrawal Reinstatement Repeat term/year Fellows designation Student-at-large/Non-degree-seeking Graduation Intercampus transfer Deceased Suspension What type of leave of absence?* Voluntary Administrative Student has already met with Student Affairs:* Yes No Date of meeting:* MM slash DD slash YYYY Reason for request of intercampus transfer:*Student is in good academic standing:* Yes No Student is in good professional standing:* Yes No Requested campus, program, and class year of transfer:*CAMPUSPROGRAMCLASS YEARStudent Affairs has confirmed that there is enough space in the campus, program, and class year of transfer:* Yes No Effective date of transfer:* MM slash DD slash YYYY Effective term:* Fall Spring Summer Effective year:* Graduation date:* MM slash DD slash YYYY Fellowship:* Anatomy MCOM Osteopathic Teaching Fellowship OPP Pre-doctoral simulation TYP Which COM year will you enter upon the start of the next academic year?* OMS Year 3 OMS Year 4 OMS Year 5 Which fellowship year will you enter upon the start of the next academic year?* 1st year of fellowship requirements 2nd year of fellowship requirements 3rd year of fellowship requirements What is your new anticipated graduation year?* Leave of absence:Proposed effective date* MM slash DD slash YYYY When do you intend to return?* Fall Spring Year of intended return:* 2023 2024 2025 2026 2027 Why are you leaving RVU at this time?* Academic Challenges Medical Issues Financial Reasons Career Change Family Related Personal Issues Military Related I understand that I am responsible for all financial obligations and completing all academic requirements. I will complete this form again for reinstatement at least ten weeks prior to my return to ensure that my registration records are updated and I am included in appropriate future e-mail communications.Complete withdrawal:Proposed effective date* MM slash DD slash YYYY From what semester and year are you withdrawing?* Spring 2023 Fall 2023 Spring 2024 Fall 2024 Spring 2025 Fall 2025 Is this a voluntary or involuntary withdrawal?* Voluntary Involuntary Year of matriculation:Please select.20152016201720182019202020212022202320242025Why are you leaving RVU at this time?* Academic Challenges Medical Issues Financial Reasons Career Change Family Related Personal Issues Military Related I understand that I am responsible for all financial obligations and that I will be required to apply for admission again if interested in returning to RVU in the future.Reinstatement:Returning semester:* Spring 2023 Fall 2023 Spring 2024 Fall 2024 Spring 2025 Fall 2025 Which class do you anticipate joining?* 1st year 2nd year 3rd year 4th year Did you have any change of name or change of address while you were on leave?* Yes No Please explain:*Attach additional explanation documentation, if needed.Please do not attach legal documents or any other type of sensitive material. Drop files here or Select files Max. file size: 10 MB. Is there anything else that you would like us to know?Signature*