Leave of Absence Request

Leave of Absence Request Form
 
Date:  
    
Full Name:Position/Title:
Location:Extension:
 
Leave Dates Requested:From:  To:  
 

Type of Leave/Absence (check all that apply):

Medical Leave (for use with accrued time only)
Family Medical Leave (FMLA)
Personal
Military
Other – Please explain
 
 
I Will Be Using:
Total DaysReason CodesLeave Dates
Accrued Personal Illness DaysFrom>:  To:  
Accrued Personal Business DaysTo:  
Accrued Vacation DaysFrom:  To:  
Unpaid LeaveFrom:  To:  
 
Any medical leave requires a doctor’s note for leave of absence. You will also need a medical clearance to return to work.


Security Measure