Leave of Absence Request

Leave of Absence Request Form
 
Date:  
    
Full Name:Position/Title:
Location:Extension:
 
 

Type of Leave/Absence (check all that apply):

Medical Leave (for use with accrued time only)
Family Medical Leave (FMLA)
Parenthood Leave (Must send Parenthood Leave Request form)
Personal
Military
Other – Please explain
 
 
I Will Be Using:
Total DaysReason CodesLeave Dates
Accrued Personal Illness DaysFrom: To:  
Accrued Personal Business DaysFrom: To:  
Accrued Vacation DaysFrom: To:  
Unpaid LeaveFrom:  To:  
 

Any medical leave requires a doctor’s note be sent to the Leave of Absence email address noted below. You will also need medical clearance to return to work.

Health insurance coverage will continue for up to twelve (12) weeks of unpaid leave if the required health insurance contribution is received. After twelve (12) weeks of unpaid leave or if your contribution is not received, your health insurance benefits will be terminated, and an offer of COBRA coverage extended to you at the full cost of the health insurance premium.

All communication pertaining to Leave of Absence should be sent to: [email protected]

 



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