CITY OF HICKORY
LEAVE REQUEST FORM
Refer to the City of Hickory Leave Policy
Modified 10/13/20
Date: ___________
Employee Name: _________________________ Department: ____________
Supervisor: _________________________
TYPE OF LEAVE REQUESTED: ☐ FMLA (COMPLETE FMLA SECTION BELOW)
☐ FMLA WORKERS’ COMPENSATION (CONCURRENT WITH FMLA)
☐ LEAVE WITHOUT PAY
☐ SICK LEAVE (NOT FMLA)
DATE WHEN LEAVE WILL START: _________
DATE ANTICIPATED TO RETURN TO WORK: ____________
If leave time will be intermittent, list the schedule of time needed off: ____________________________________________
Note: If leave is for medical reasons, certification from your health care provider may be required.
IF REQUESTING LEAVE WITHOUT PAY, LIST REASON FOR ABSENCE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
IF REQUESTING FMLA:
Does your spouse work for the City of Hickory: ☐YES ☐NO
Reason for taking leave: (check one)
☐The birth of my newborn child or placement of a child with me for adoption or foster care.
☐To care for my spouse, child, or parent who has a serious health condition.
☐My own serious health condition that makes me unable to perform at least one of the
essential functions of my job.
☐To care for my spouse, son, daughter, parent or next of kin who is a covered service
member with a serious injury or illness.
FMLA and WORKERS’ COMPENSATION LEAVE: I understand that the City will pay its portion of my medical, dental and life insurance for
up to twelve weeks in my consecutive twelve-month period. This twelve-month period is the twelve-month period measured forward
from the first time a coworker was approved for FMLA. If my leave exceeds twelve weeks in that period and I have exhausted all accrued
leave and compensatory time, I will be on Leave Without Pay and will be responsible for the full cost of the above insurance. I understand
that I am obligated to return to work at the end of the leave period. Failure to report shall be considered a resignation, and I may be
required to reimburse the City for the cost of my insurance premiums during the 12 week FMLA leave. I understand that I will cease to
earn vacation and sick leave on the date that my Leave Without Pay exceeds five working days. Leave Without Pay, including concurrent
FMLA, shall not exceed six (6) months.
LEAVE WITHOUT PAY (non-FMLA/Workers’ Compensation): I understand that I am responsible for paying all of the cost of my insurance
including medical, dental and life once all accrued leave and compensatory time is exhausted. I understand that should my premium
payment to the City become 30 days past due, my insurance coverage will lapse at that time. I understand that I will cease to earn
vacation and sick leave on the date my Leave Without Pay exceeds five working days. Leave Without Pay shall not exceed six (6) months.
____________________________________________________ _________________________
Employee Signature Date Signed
____________________________________________________ _________________________
Supervisor’s Signature Date Signed
____________________________________________________ _________________________
Department Head Signature Date Signed
____________________________________________________ _________________________
Human Resources Signature Date Signed
If request for Leave Without Pay, non-FMLA, exceeds five (5) days, the City Manager’s approval is required.
____________________________________________________ _________________________
City Manager’s Signature Date Signed
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