Fillable Short Term Disability Leave Request

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Short Term Disability Leave Request

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The Short Term Disability Leave Request form is 1 page long and contains:

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  • 8 check-boxes
  • 9 other fields

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BROWSE CITY (AR) FORMS

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01/2014
SHORT-TERM DISABILITY
LEAVE REQUEST FORM
________ _________________________
Employee Name Employee Number Date
I am requesting Short-Term Disability (STD) for the dates below. I am charging the first three days of
absence to Paid Time Off (PTO) or Leave Without Pay. If applicable, I have attached medical
documentation showing my length of absence. Below I am requesting the PTO that needs to be charged,
or showing the dates that I have already been charged PTO, showing I am eligible to charge STD.
I am requesting STD for:
Injury/Illness lasting more than three days: I am charging a total of 24 PTO hours
Sick Family: I am charging 24 PTO hours related to this relative and condition
Birth/Adoption of a child: I am charging a total of 24 PTO hours for this event
Ongoing Injury/Illness occurring within the last thirty days from the last related absence and I have
charged a total of 24 PTO hours
Chronic Condition and I have charged a total of 24 hours related to this condition
Dates that I have already been charged related to this absence
____________________________
PTO Leave Dates Time Begin/Time End
Or Leave Without Pay
Total Time Requested – PTO/Leave Without Pay
____________________________
STD Leave Dates Time Begin/Time End
Total Time Requested – STD
____________________________
Department Director’s Signature Date
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Short Term Disability Leave Request

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Completed 21 March 2020

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