Leave Of Absence Request Form printable pdf download

, S

NIVERSITY OF

ALIFORNIA

RANCISCO

Leave of Absence Request

EMPLOYEE: PLEASE FILL OUT TOP PORTION

Employee:

Phone:

Campus Phone:

Department:

Title:

Employee ID:

Reason For Leave of Absence:

Initial Application

Own Illness (not work related)

Union Business

Administrative

Amendment

Care for Ill Parent/Spouse/Child

Work-Incurred Injury

Military

Pregnancy Disability

Furlough

Other (specify)

(Specify date of last LOA request)

Care for Newborn/Placed Child

Professional Development

Date of Birth/Placement:_________

Requested start date:

Requested intermittent or reduced work schedules:

Anticipated return date:

Have you or will you be filing a University Disability Insurance claim?

yes

A leave of absence is normally leave without pay. Paid leave (accrued sick, vacation, or CTO) shall be substituted for all or

a portion of the unpaid leave in accordance with the appropriate policies/contracts.

I wish to use paid leave as indicated below: (attach additional sheets if necessary)

Hours of accrued sick leave

Begins on

and ends on

Hours of accrued vacation

Begins on

and ends on

Hours of accrued compensatory time off

Begins on

and ends on

(not for use with Family & Medical Leave)

Employee's signature:

Date:

DEPARTMENT: PLEASE FILL OUT BOTTOM PORTION

APPROVAL/DENIAL OF LEAVE REQUEST

Your requested leave is approved, and

___/___

days/weeks qualify as FML leave under Federal law

Begins on __________

and ends on ___________

___/___

days/weeks qualify as FML leave under State law

Begins on __________

and ends on ___________

___/___

days/weeks qualify as (specify) _______________

Begins on __________

and ends on ___________

Family and Medical Leave

Your requested for family or medical purposes does not meet the requirement under Federal/State law for the following

reason(s):

Other Leaves

Your requested leave is not approved for the following reason(s):

PAY STATUS DURING LEAVE

Sick Leave

______ hours to be applied