Fillable Extended Leave Of Absence Request Form printable pdf download

Extended Leave of Absence Request Form

Except in emergency situations, this form is to be completed PRIOR to the use of extended leave.

Please attach a projected attendance sheet for leave requests longer than one month.

Employee Section:

Home or Mobile

Name

Phone Number

Paid Medical (sick leave)

Unpaid Family Leave

Type of leave requested:

Check more than one if taking both

Unpaid Medical Leave

Unpaid Personal Leave

paid and unpaid time.

Estimated

Last day

First unpaid day,

return date:

present at work

if applicable:

REQUIRED, if requesting use of sick time:

Number of

days available :

days requested:

If the request is due to an accident/injury, was the accident/injury at work or work-related?

Yes**

**If you answered "yes" to the above question, please call (217) 524-9535 to request Workers' Compensation information and/or forms.

Employee Acknowledgement, Approval to Release Medical Records, and Signature:

I acknowledge and understand that if I am on unpaid leave that I may be billed for insurance premiums by Central

Management Services. I understand that non-payment of billed insurance premiums may result in payroll deductions and/or

termination of my insurance coverage. I also understand that paid or unpaid leaves of absence which qualify as leave provided

under the Family and Medical Leave Act will be counted toward my annual entitlement of FMLA leave. I acknowledge that

the FMLA provisions have been provided to me in the Administrative Regulations.

I authorize my health care provider listed below to release the information requested in order to support this leave of absence.

Employee Signature _______________________________________________Date ____________________

Physician's Section:

This section must be completed by the attending physician OR a physician's statement must be attached for

medical leave. If a physician's statement is provided, it must include: (1) the date the leave will begin, (2) an

expected date of return, and (3) the general nature of the disability.

This is to certify ____________________________________ is under my professional care. The above

named employee is:

(check one)

unable to perform his/her required job duties due to the condition listed below.

the primary caregiver for my patient with the condition listed below.

Beginning leave date: ___________________

Estimated return date: ________________*

Nature of Disability or Illness/Physician Comments:_______________________________________________

_________________________________________________________________________________________

Physician's Name _______________________________________ Phone # ___________________________

Address

Signature _______________________________________________ Date ____________________________

*If the return date changes from the original approved time period, an updated physician's statement must be submitted.

Page 1 of 2

Rev. 11/2014

Extended Leave Of Absence Request Form

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