Leave of Absence Request

Staff Name: Office Base: MTD ORM KIS

Contracted Staff may request a Leave of Absence (LOA) up to 3 months for any reason. LOA requests can be approved by the Program Manager (PM), or both PMs (if providing services in two programs) only upon:

1.Submission of LOA Request form to the PM(s)

2.Discharge or transfer of all open cases

  1. Discharge paperwork submitted to Compliance Specialist
  2. Transfer paperwork (Other Services Request form) submitted to Referral Coordinator

3.Submission of all documentation for any outstanding services (with billing log)

4.Correction of all items in his/her Correction Folder

  1. at the time of the LOA request AND
  2. upon notification that final billing has been processed (within a week)

5.LE’s: Completion of all items in his/her LE folder

Employees may request a Leave of Absence (LOA) up to 12 weeks. Requests should be submitted in writing at least 2 weeks in advance whenever possible. LOA requests may be approved by the Human Resources Managerfor the following:

  1. situations that fall under the Family Medical Leave Act of 1993
  2. situations that fall under F.S. 741.313 related to domestic violence victims
  3. other situations approved by the Executive Director

Reason for request:

Expected last date of work prior to leave of absence:

Expected date of return to work*:

*Contractors may not exceed 3 months between dates of service

Date two weeks prior to expected return to work*:

*Contractors should begin accepting referrals in order to resume service provision by expected return date

I have read and agree to the conditions listed above. I understand that during the last two weeks of an LOA it is my responsibility to remain responsive to Adapt email communication. I agree to notify Adapt if any of my contact information (email address, phone number, mailing address) changes. I agree to initiate contact with my PM(s)/direct supervisor by ______(date), approximately two weeks prior to the end of this LOA.

Staff Signature: ______Date: ______

For office use only:

This request for leave of absence is:

approved not approved qualified approval, as follows:

Actual last date of work/service was: Calendar prompt entered for date:

Manager/Administrator Signature: ______Date: ______