Department Of Children And Families Office Of Human Resources Leave Of Absence Forms Page 2
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1
2
3DEPARTMENT OF CHILDREN AND FAMILIES
OFFICE OF HUMAN RESOURCES
LEAVE OF ABSENCE REQUEST FORM
EMPLOYEE’S NAME: _____________________________________SS#/EMP ID_________________
CIVIL SERVICE TITLE: ________________________ HOME EMAIL ADDRESS:________________
WORK LOCATION: ______________________________________ COST CODE #_______________
HOME PHONE: ___________________________ WORK PHONE: _____________________________
HOME ADDRESS: ____________________________________________________________________
ANTICIPATED DATES OF LEAVE: FROM___________________ TO:___________________
TYPE OF LEAVE OF ABSENCE: NEW LEAVE REQUEST
EXTENSION REQUEST
CONSECUTIVE (10 or more consecutive days)
REDUCED/INTERMITTENT
DO YOU INTEND TO APPLY FOR TEMPORARY DISABILITY INSURANCE (TDI)? YES
NO
DO YOU INTEND TO APPLY FOR FAMILY LEAVE INSURANCE (FLI)?
YES
NO
(If yes, TDI & FLI Forms Should Accompany This Request)
*TYPES OF MEDICAL LEAVES:
MEDICAL LEAVE
FAMILY MEDICAL LEAVE
(ELIGIBLE EMPLOYEE)
(CARE FOR ELIGIBLE FAMILY MEMBER)
**OTHER TYPES OF LEAVES:
MILITARY LEAVE
LEAVE AS WITNESS
SCHOOL VOLUNTEER
LEAVE FOR CHILD
CONVENTION LEAVE
OTHER
BONDING
EMERGENCY CIVILIAN
DUTY
DO YOU WISH TO USE YOUR ACCRUED VACATION TIME?
YES
NO
ADMINISTRATIVE LEAVE?
YES
NO
COMPENSATORY TIME?
YES
NO
SICK TIME?
YES
NO
EMPLOYEE NARRATIVE/COMMENTS (ATTACH ADDITIONAL SHEETS IF NEEDED):
* ATTACH THE COMPLETED WH-380E or WH-380F AS APPROPRIATE.
** ATTACH ALL SUPPORTING DOCUMENTATION REQUIRED PER THE DEPARTMENT
POLICY
THE INFORMATION CONTAINED ON THIS FORM AND THE SUPPORTING DOCUMENTATION
ATTACHED IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
___________________________________________________
____________________
EMPLOYEE’S SIGNATURE
DATE
Page 1
Office of Human Resources
Version 3.0 Revised 1/2014
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