Request for Leave of Absence Form
Faculty
Staff
Please complete and return this Form to your immediate supervisor 30 days
in advance of Leave, if possible. SEND COMPLETED FORM TO HR.
EMPLOYEE INFORMATION
Employee Name
A #
Home Address City State Zip
Job Title/Department Telephone Number
Home Cell
Camp
us Email
Reason for Leave Request (If necessary, attach additional sheet)
Requested Start Date Anticipated Return Date
TYPE OF LEAVE
General Leave of Absence (Not to exceed 6 months) Medical Leave of Absence (Not to exceed 6 months)
* *
MEDICAL LEAVE OF ABSENCE
Leave for reasons of prolonged illness or other justifiable medical
conditions may be granted to full-time employees with a year or more of
continuous regular service. Medical leave is without pay. Available sick
and vacation leave should be utilized before medical leave begins. A one-
time extension, not to exceed 6 months, may be granted on a case-by-
case basis with appropriate medical certification. The total amount of
time an employee can be on an approved medical leave of absence is
one (1) year.
GENERAL LEAVE OF ABSENCE
Leave for personal reasons may be granted to full-time
employees with a year or more of continuous regular service.
General leave is without pay. Normally, all accrued vacation and/
or sick leave (if appl
icable) must be exhausted before a general
leave of absence begins; however, an employee may request to
take such leave without affecting accrued leave account
balances.
*The determination process includes consideration of factors such as the duration of leave requested, the workload of the
department, and the ability to reassign the employee's duties.
A completed
Medical Certification f
orm is required to support a Medical Leave of Absence request.
Click on the hyperlink or contact HR to obtain the form.
A completed Medical Certification form is attached
I will submit a Medical Certification form within 5 days to Human Resources
APPROVALS
Immediate Supervisor/Dept. Chair: Director/Dean:
Vice President:
Date: Date: Date:
Approved
Submit ePAF
Approved
Approve ePAF
Approve ePAF
Not Approved Not Approved
Approved
Not Approved
Employee Signature: ______________________________
Date: __________________
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