Send Completed Form to Human Resources
Please refer to the Employee Handbook for complete descriptions of the various types of leave available.
General Information
EMPLOYEE ID NUMBER
Type or Print Employee Name Date
Department
Supervisor
I request leave beginning at
on
, ending at on for
Time Date Time Date
a total of
hours.
Check
√
one of the following reasons:
Employee Signature Date
Approved:
Supervisor Signature Date
Family or Medical Leave
I request Family or Medical Leave (FMLA) for the following reason:
Check
√
one of the following reasons:
Spouse, Child, Parent for which you are needed to
start on and is expected to end on .
Date Date
Medical certification supporting the need for an employee to care for their own, or their spouse’s, child’s or parent’s
serious illness is required. Medical certification forms are available in the Human Resources Office.
Medical Certificate is attached.
The requesting employee will be notified of the status of the request within two working days of the request being
Received in the Human Resources Office.
Employee Signature Date
HOURLY SALARIED
Annual Leave – Annual leave needs to be requested at least 3 working days in advance
Sick Leave - Sick leave is used when conditions do not permit the use of Family or Medical Leave
Emergency Leave - Up to three consecutive days per year for family members specified in Handbook
Funeral Leave - Up to three consecutive days for family members specified in Handbook
Military Leave - Up to three weeks per year
Jury Duty - Summoned to appear for jury duty
Court Leave - Subpoenaed to appear in court as a witness
Compensatory Time
Personal Day - One day per calendar year
Leave without Pay - for use when sick and annual leave is unavailable
Request and Authorization for Leave
provide care.
Leave Form
A serious health condition that makes you unable to perform the essential functions of your job.
A serious health condition affecting your
The birth of your child, or the placement of a child with you for adoption or foster care. This leave needs to
