PA-5: Leave of Absence Request Form
(for Full-Time Facu
lty and Staff)
Please print or type all information.
(Rev. 6/2009)
1. Employee’s Name ______________________________________________________________________________________
(Last, First, Middle)
2. Social Security Number _______________________________________ 3. Ext. ________________
4. Leave Request Start Date: / 20____
5. Expected Leave End Date: / 20____
6. Reason for Requesting Leave of Absence:
Medical Leave due to the “Serious Health Condition” of:
Employee Employee’s Family Member
A “serious health condition” is “an illness, injury, impairment, or physical or mental condition that involves inpatient
care in a hospital, hospice, or residential care facility; or continuing treatment by a health care provider.”
“Continuing treatment by a health care provider” must include either (1) a period of incapacity lasting more than
three consecutive calendar days and treatment two or more times by a health care provider, or (2) treatment by a
health care provider on one occasion resulting in a regimen of continuing treatment under the provider’s supervision.
Please indicate family member’s name and relationship to employee:
__________________________________________________________________________
Maternity/Paternity Leave
Sabbatical
Military Leave
Personal Leave Unpaid Time-Off Paid Time-Off
7. Memo __________________________________________________________________________________________
8. Supervisor ______________________________________________________________ Ext. ____________________
SIGNATURES
Supervisor __________________________________________________________ Date _____________________
Vice President ________________________________________________________ Date _____________________
Human Resources _____________________________________________________ Date _____________________
