Application For Extended Leave Of Absence Page 2
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REQUIRED DOCUMENTS
FAMILY AND MEDICAL LEAVE ACT (FMLA)
1.
Childcare:
FMLA package and birth certificate, adoption papers or
foster care certification.
Medical:
FMLA package completed by a physician explaining
medical condition and indicating leave start and end date.
Family Care:
FMLA package completed by a physician indicating family
member requiring care, explanation of the medical
condition and estimated period that care needs to be
given.
MEDICAL LEAVE:
Written request to the Assistant Commissioner for
2.
Human Resources together with medical documentation
signed by the attending physician (including physician’s
license number/stamp). Documentation must indicate
diagnosis, prognosis, date the condition manifested,
specific
limitations,
explanation
of
treatment,
and
expected return to work date.
CHILD CARE LEAVE:
Written leave request must be submitted to employee’s
3.
immediate supervisor and Bureau Head. A copy of the
child’s birth certificate must be attached to the leave
request. Requests should be made six weeks prior to the
date of anticipated leave.
PERSONAL LEAVE:
A letter of request, via the Bureau Head, addressed to the
4.
Assistant Commissioner for Human Resources detailing
the reason for the request. Letter must include a start
and end date. Additional documentation may be required.
ADVANCED LEAVE:
A letter of request, via the Bureau Head, addressed to the
5.
Assistant Commissioner for Human Resources detailing
the reason for the request. The Bureau Head will forward
his/her
written
recommendation
to
the
Assistant
Commissioner for Human Resources for consideration.
Additional documentation may be required.
MILITARY LEAVE:
Employee must submit military orders. Form DD-214
6.
must be submitted upon return along with Leave and
Earnings Statement (LES)
DISCRETIONARY
Written request to the Assistant Commissioner for
7.
GRANT:
Human Resources together with medical documentation
signed by the attending physician (including physician’s
license number/stamp). Documentation must indicate
diagnosis, prognosis, date the condition manifested,
specific
limitations,
explanation
of
treatment,
and
expected return to work date.
Rev 05/12
HR-07-02
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