LEAVE OF ABSENCE REQUEST FORM
Complete this form for a leave of absence greater than ten (10) days.
For an explanation of Leaves of Absences, please refer to the relevant Agreement and/or Policy covering your position.
Benefits may change depending on the type of leave; contact your HR Service Associate for details.
Employee Information
Employee Name: Employee Number:
Employee Department: Department Number:
Leave Information
Type of Leave:
Start Date of Leave:
End Date of Leave (if known):
*Will you be collecting Employment Insurance benefits based on the standard or extended parental benefits?
Please check the relevant benefit:
Extended benefit (61 weeks)
Standard benefit (35 weeks)
Signatures
Employee’s Signature:
Date:
Signature of Approving Supervisor, Director, or Chair:
Date:
Upon completion of this form, please forward to your Human Resources Service Associate with an
appropriately completed employee data form.
HR USE ONLY
Received Date: Approval Date:
Notes:
Revised: July 2018
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