Employee Request for Leave Form

Instructions: Complete this from and click submit. The form will be forwarded to the Human Resources Office.

Employee Information

First

Last

Date of Request

Date of hire

My Immediate Supervisor's Name

My regular work schedule is (check all that apply):

Sun

Mon

Tues

Wed

Thurs

Fri

Sat

Type of Leave Being Requested

Certification (s) of medical need for leave, adoption/fostering certification, active duty documentation, call to duty documentation or proof of attendance for jury duty will be required.

I hereby request a leave of absence for the following reason:

For the birth of my child.

Because I am adopting/fostering a child.

Because of a serious health condition that prevents me from performing the essential functions of my job.

Because I am needed to care for my spouse, child* or parent who has a serious health condition.

Leave to care for a spouse, son, daughter, parent, or next-of-kin who incurred an injury or illness in the line of military duty.

Leave for a qualifying exigency due to a spouse, son, daughter or parent's active military duty or call to duty.

Because I have been called to military duty.

Because of the death of a family member.

Because of a call to jury duty.

If applicable, expected Date of Birth or Placement

If applicable, person Needing Care and Relationship to you

If applicable, deceased person's name and relationship to you

*Is the child under the age of 18 or do they have a disability which renders him/her incapable of self-care?

Yes

Amount of Leave

I request the leave be granted for the following period of time:

Leave begin date

Leave end date

I anticipate returning to work on:

I request the leave be:

Continuous

Reduced Hours**

Intermittent**

**Specifics of the schedule request:

My Address during the period of the leave will be:

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

By submitting this form, I hereby certify that the information given above is true and correct to the best of my knowledge. I understand that misrepresentation or omission of the reason for leave or any of the facts supporting the need for leave will result in denial of the leave and will subject me to discipline up to and including termination.