Form 36609 - Request For Leave Of Absence Page 2
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Form
REQUEST FOR LEAVE OF ABSENCE
36609
Page 2 of 2
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UPERVISOR/DEPARTMENT ADMINISTRATOR/HR - Please use this form to indicate leave type and length of leave.
Complete all required information (if applicable) in writing and provide attachments as indicated.
Name (Last, First, Middle):
UMID:
Note: Verify last day of pay with timekeeper or payroll representative
Date Paid Time Ends: ______________________
for staff members only.
Pmod:
Leave Information
End Date:
Begin Date:
Leave Type:
FMLA PMOD:
Is a portion of this leave covered under FMLA?
Yes
No
If yes, list dates covered under FMLA below.
Paid Begin Date:
Unpaid End Date:
Paid End Date:
Unpaid Begin Date:
If FMLA leave is more than 12 weeks, indicate reason and/or comments below.
Please indicate date employee was notified of FMLA status or attach copy of notification letter. Date: __________________________
No
Yes
Notification Letter Attached:
Pmod:
Extension of Leave
Leave Type:
Extension
Extension
Begin Date:
End Date:
Authorization
Contact/Preparer Name:
Phone:
Date:
Contact/Preparer Signature:
HR Rep Name:
Phone:
HR Rep Signature:
Date:
FOR HRRIS USE ONLY
Empl Rcd#
Effdt
Eff Seq
Act/Reason
Form 36609
Available at:
Revised 11/10
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Parent category: Business