LEAVE OF ABSENCE REQUEST FORM
Name:________________________________ Date: ___________________
Department: _____________________
Type of Leave Requested:
Medical Leave ( ), FMLA Leave ( ), Personal Leave ( ), Other ( ) Leave Start Date: __________________Return Date: ____________________
Reason for Leave:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Read carefully the following, and initial each blank to signify understanding.
________ |
I understand that my leave of absence is without pay, other than authorized |
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in the Leave of Absence Policy, and that the duration of any leave is at the |
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discretion of the department head. |
Medical and personal leave may not |
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exceed six months; FMLA Leave cannot exceed twelve weeks. |
________ |
I understand that I must return to work, or request an extension, by |
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___________ or I will be deemed to have voluntarily terminated my |
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employment on that date. |
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________ I understand that I must submit |
a written physician’s release to the |
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Administrative Office in order to return to work from a Medical Leave of |
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Absence. |
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________ For other than FMLA Leave, I understand that my present position may not
be available either due to a need to fill the vacancy or due to a medical
condition related to my release. |
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__________________________________ |
_____________ |
Employee Signature |
Date |
_________________________________ |
______________ |
Department Head |
Date |
_________________________________ |
______________ |
Administrative Office |
Date |