REQUEST FOR LEAVE OF ABSENCE
Last Name: ___________________________ First Name: ________________________ M.I._____
Date of Hire: __________________________ Last 4 digits of SSN: ___________________________
Position: _____________________________ Department: ________________________________
Supervisoƌ͛ƐEĂŵĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Phone #: ____________________________________
L
eav
e Start Date: ______________________ Leave End Date: ______________________________
Leave Type: Check all that apply
ٯ Disability
ٯ M i l i t a r y
ٯ FMLA
ٯ Paid Family Leave
ٯ
ƌŬŵĂŶ͛ƐŽŵƉĞŶƐĂƚŝŽŶ
ٯ Per
sonal
Purp
ose:
ٯ Illness/injury/incapacitation of requesting employee
ٯ Care of family member, including medical/dental/ or bereavement
ٯ Care of family member with a serious health condition
ٯ Parental Leave (Birth, Adoption, Foster Placement)
ٯ Other
____________________________________________________________________
1. Have you taken a leave of absence in the past 12 months? පz^පEK
2. Is this a request for intermittent leave? පz^පEK
3. Is this a work-related illness or injury? පz^පEKIf yes, please complete an injury report so a
tŽƌŬĞƌƐ͛ŽŵƉĞŶƐĂƚŝŽŶĐůĂŝŵĐĂŶďĞĨŝůĞĚǁŝƚŚŝŶϱĚĂLJƐŽĨƚŚĞŝŶũƵƌLJ͘
I certify that the leave/absence requested above is for the purpose(s) indicated. I understand that I must comply
with Daemen's procedures for requesting leave/approved absence and provide additional documentation,
including medical certification, military documentation, etc. In addition, I recognize that I will need to make
arrangements for payment of my health/benefit premiums either as a payroll deduction, pre-payment prior to
leave, or monthly payment plan as arranged with the Employee Engagement Office.
_________________________________________ ________________
Employee Signature Date
_________________________________________ ________________
Supervisor Signature Date
REQ_LOA_0619
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