Department Of Children And Families Office Of Human Resources Leave Of Absence Forms Page 3

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DEPARTMENT OF CHILDREN AND FAMILIES
OFFICE OF HUMAN RESOURCES
LEAVE OF ABSENCE REQUEST FORM
EMPLOYEE’S NAME: _____________________________________SS#/EMP ID_________________
WILL THIS LEAVE OF ABSENCE POSE AN UNDUE HARDSHIP ON THE OPERATIONS OF
YOUR OFFICE/COST CENTER? YES
NO
IF YES, PLEASE COMPLETE OFFICE
MANAGER’S/ COST CENTER MANAGER’S OPERATIONAL NEEDS STATEMENT BELOW.
OFFICE MANAGER’S/COST CENTER MANAGER’S OPERATIONAL NEEDS STATEMENT:
Instructions - Provide a statement outlining the current operations of your office. Please identify staffing levels
in relationship to MSA compliance, approved staff leaves and suspensions, vacancies, and the number of new
employees in training period. List any significant office initiatives or projects as applicable.
_____________________________________________________
____________________
OFFICE MANAGER/COST CENTER MANAGER
DATE
_____________________________________________________
SIGNATURE
OHR Use Only
Approved
Disapproved
Type of Leave_________________________
Leave Authorization
Notification
Reviewed by__________________________________
Date________________
Page 2
Office of Human Resources
Version 3.0 Revised 1/2014

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