Feedback/ Request Forms : choiceshr.com

Request for Leave of Absence

*Your Email Address:

   * Name

   * Date

   * Program/Location

   * Position

   * SS#

   * Supervisor

   * Classification: Full Time Hours per Week

   * Part Time Hours Per Week

   * Schedule: List days and hours for each day

   *

Duration of leave: Anticipated Start Date

   * Anticipated Return Date

   * Type of leave requested: Medical
   * Birth and care of newborn child
   * Care of a seriously-ill child, spouse or parent
   * Employee's own serious health condition
   * Personal
   * Military
   * Provide a detailed explanation for your request for leave of abscence

If request is for partial leave, what days and hours do you expect to be gone?

   * Do you want to apply paid time off ( if available) to your leave of absence