Leave of Absence Approval Form
I understand that in accordance with the Family and Medical Leave Act of 1993 (FMLA), employees are provided
leave, and I acknowledge that I have been provided with notice of my rights under the FMLA. I understand that I am
to comply with the leave policy, including completion of this form. I also understand that leaves of absence are to be
approved by the Department Head and are approved for periods that will exceed three working days and that leaves
cannot exceed 12 weeks per 12-month period, unless state law provides for more, in which case those limits apply. I
understand compensation and performance reviews are postponed by the amount of leave.
Employee Name (print):______________________________SS# ___________________________
Store Location ______________________________(City/State)_____________________________
Current Position: ________________________________________
I hereby request a Leave based on the following: (check one)
If "Personal Leave," please provide a brief statement as to the nature of the leave.
If you have any accrued paid leave, that paid leave must be applied to this leave before any unpaid leave time.
I understand that a medical leave is the period of time my physician says I cannot work until the time the physician
says I can return to work. All requests for personal medical and family leave due to the serious illness of a family
member must include a physician's statement. For a leave based on my illness, a physician's release showing I am
able to resume my normal job, or any restrictions, must be provided to my supervisor before I may return to work.
Failure to provide the physician's statement may lead to the denial of a leave, denial of the continuation of leave, or
denial of reinstatement. My medical leave will end if my physician releases me to return to work, either on a part-time
basis or with certain restrictions, and the company agrees to accommodate my physician's instructions by
temporarily modifying my job. If I do not accept the modified position, I must either apply for a personal leave or
terminate my employment.
My leave will begin on:____________________________________(month/ day/ year)
I will return to work on:____________________________________ (month/ day/ year)
I understand that upon my return to work on the date indicated, the company will reinstate me to my former position
or an equivalent one, in accordance with applicable law and company policy. However, I have no greater right to
reinstatement than if I had been continuously employed during the FMLA leave period. I understand that certain
changes in hours or schedules may occur due to business necessity.
If I fail to return to work on the return date (unless further approval is obtained), (or within the time limits
described if the return date is blank), I will be considered as having voluntarily resigned effective on my last day of
I acknowledge that it is my responsibility to remain in contact with my supervisor during my leave, and I agree to
contact my supervisor at least once a month regarding my status and my intent to return to work. During my leave, I