Aug - 2011
REQUEST FOR LEAVE OF ABSENCE
PLEASE COMPLETE AND FORWARD TO
HUMAN RESOURCES SERVICES
B
C
I REQUEST A LEAVE OF ABSENCE FROM _____________________ TO_____________________ INCLUSIVE.
D
_________________________________
E
IN CASE OF PREGNANCY/PARENTAL LEAVE FOR A CONTINUING EMPLOYEE:
It is my intention to return to work in my department at the end of the above mentioned period of pregnancy leave.
EMPLOYEE’S INITIALS: ______________________
F
IN CASE OF PREGNANCY/PARENTAL LEAVE FOR AN EMPLOYEE UNDER A LIMITED TERM
APPOINTMENT:
Appointment end date:_________________________
I understand that if I qualify for benefits under the SUB plan, my entitlement to those benefits will cease on the end
date of my appointment, unless the appointment is extended.
EMPLOYEE’S INITIALS: ______________________
• A Record of Employment (ROE) is required if you wish to apply for Employment Insurance Benefits.
• An ROE will be issued electronically to Service Canada after you receive your last regular pay deposit. Please
contact your Human Resources Representative, should you require a hard copy.
• For leaves of absence less than one month in duration, unless otherwise indicated, it is assumed your benefit
and
pens
ion plan coverage will continue and the applicable premiums will be deducted on your first pay deposit upo
n
your return to work.
• For Employment Insurance purposes, we recommend that you start your Pregnancy/Parental Leave on a Sunday
and end it on a Saturday.
Please note that in the case of a pregnancy leave request, either section “E” or “F” above must be completed by
the employee.
1.
DEPARTMENT HEAD AND/OR DESIGNATE:
Please Print Name and initial here
DATE: _____________________
3.
HUMAN RESOURCES: ________________________________
DATE: _____________________
cc: Dean’s Office for all Faculty Leaves only
cc: Provost’s Office for all Faculty Leaves only
cc: Faculty Relations Office – FHS for all Faculty Leaves only
The information gathered on this form is collected under the authority of the McMaster University Act, 1976. The information is used for the academic,
administrative, employment-related, financial and/or statistical purposes of the University including, but not limited to, admissions; registration and maintaining
records; awards and scholarships; convocation; provision of student services, including access to information systems; alumni relations; and disclosure to or on
behalf of the applicable McMaster student government. This information is protected and is being collected pursuant to section 39(2) and section 42 of the
Freedom of Information and Protection of Privacy Act of Ontario (RSO 1990). Questions regarding the collection or use of this personal information should be
directed to the University Secretary, Gilmour Hall, Room 210, McMaster University
.
click to sign
signature
click to edit
![]()
