[COMPANY]

REQUEST FOR LEAVE OF ABSENCE

Employee: Position:

Date of Request: Department Head:

I hereby request the following period of time off from my employment: (date) through (date) for the reason(s) checked below:

CHECK ALL THAT APPLY:

Illness or non-work-related injury

Work-related injury or illness

Date of injury

Date injury first reported

______Pregnancy, childbirth or related medical condition

______My own "serious health condition" (a "serious health condition" is an illness, injury, impairment or physical or mental condition which involves inpatient care [i.e., an overnight stay] in a hospital, hospice, or residential health-care facility or any period of incapacity requiring absence from work, school, or other regular daily activities, of more than 3 calendar days, that also involves continuing treatment, which generally means two or more visits to a health-care provider, by (or under the supervision of) a health-care provider or continuing treatment by a health-care provider for a chronic or long-term health condition that is incurable or so serious that, if not treated, would likely result in a period of incapacity of more than 3 calendar days or any period of incapacity or treatment due to a chronic serious health condition or due to pregnancy or pre-natal care).

A certification form will be provided for your health-care provider to complete. The form must be submitted to Human Resources within 15 calendar days.

______Absence due to a "serious health condition" of my child, spouse or parent

Relationship of individual to you ______

A certification form will be provided for the health-care provider to complete. The form must be submitted to Human Resources within 15 calendar days.

______Birth of my child

Date of birth or expected birth ______

______Placement of a child with me for adoption or foster care

Date of placement or expected placement ______

______Military Leave (Active or Reserve) B a copy of your orders must be attached

______Jury Duty Leave B a copy of the notice or summons must be attached

______Witness Duty Leave B a copy of the subpoena must be attached

______Bereavement/Funeral Leave

Relationship to deceased: ______

Date of Death: ______

______Personal leave (explain): ______

By submitting this request, I hereby acknowledge receiving a copy of the [Company] leave of absence policies contained within the Employee Handbook. I further acknowledge that leaves of absence may be concurrently charged against my entitlement to leave under all appropriate federal and state laws and that all requests are subject to approval by my Department Head and the Human Resources Director.

I certify that the above statements are true.

______

DateEmployee's Signature

P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this form, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this website, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained.PAS Rev. 4/97