Leave Request/notification Form printable pdf download

EAVE

EQUEST

OTIFICATION

ORM

Employee Information

Name ______________________________ R‐No. ________________ Best Contact No. __________________

Department ___________________________________ Supervisor ___________________________________

II.

Type of Leave Requested

FMLA

NON‐FMLA

 Medical‐ Self

 Personal

 Medical‐ Family Member

 Domestic Violence

 Military Duty Leave

o Relationship _________________

 Parental: Childbirth or Adoption‐ Staff

 Parental: Childbirth or Adoption‐ Faculty

 Military: Qualifying Exigency

 Military: Serious Injury or Illness of Covered Servicemember

III.

Anticipated Dates of Leave

From __________________ To __________________ Expected Return to Work Date ____________________

IV.

HR Contact/Receipt of Documents

Please contact Human Resources for additional required documentation related to the type of leave requested.

Documentation Provided ‐

FMLA:  Designation Notice  Eligibility Rights  FMLA Poster  CHCP‐ Employee  CHCP‐ Family Member

Military:  CHCP‐ Servicemember  CHCP‐ Exigency

Non‐FMLA: see specific policy for appropriate documents

HR Representative ___________________________________________

____________________

Signature

Date

I acknowledge that I have been provided the leave documentation listed above and that it has been thoroughly

explained to me. I understand that it is my responsibility to review this information and return the required

documentation prior to the start of leave. If my absence is for an FMLA qualifying event, I understand that the

absence (paid or unpaid) will count toward my 12 weeks of FMLA entitlement. Any questions should be directed

to Human Resources.

Employee __________________________________________________

____________________

Signature

Date

Supervisor Signature

I certify that the above listed employee has notified me of their request for leave.

Supervisor __________________________________________________

____________________

Signature

Date

Please return this document to the leave administrator checked below; Box 2718 or Fax (407) 646‐2188:

 Oriana Guevara (407) 646‐2356  Christy Gomez (407) 975‐6453  David Zajchowski (407) 646‐2105

Leave Request/notification Form

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