Staff Request For Leave Of Absence Form
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1Department of Human Resources
STAFF REQUEST FOR LEAVE OF ABSENCE FORM
Name:
Employee ID ____________
Department:
Extension: _________
Supervisor: ____________________________________________________________
:
to
________________
Dates of Leave Requested
(return to work date)
Reason for Leave
(please check all applicable leaves):
_________
Medical Disability*
___________
Pregnancy Disability*
_________
Industrial Disability*
___________
Other (explain below)
_________
Personal (explain below)
___________
Leave to care for a family member*
_________
Leave to care for a newborn or child after placement
_________
Jury Duty
_________
Military Duty
*Medical , Industrial, Pregnancy, and Family and Medical Leave to care for an ill family member requests require medical
certification be provided to Human Resources and where applicable, approval by the appropriate disability benefit
administrator. Approved medical, pregnancy and industrial leaves will be applied to the maximum benefit under the Family and
Medical Leave Act (FMLA) and the California Family Rights Act (CFRA) herein referred to as family and medical leave.
Refer to the Staff leave of absence guide for additional details.
During a medical, industrial or pregnancy disability leave, I understand that I must integrate my
accrued sick leave with my disability benefit as stated in the Staff Policy Manual. I further
understand that once my sick leave is exhausted, I have the option to request the use of my accrued
vacation and elect to do so as follows:
I do / do not wish to utilize my accrued vacation hours during my medical disability leave.
(circle one)
During a family medical leave, I understand that I may be required to utilize 2 weeks of accrued
but unused vacation before receiving Paid Family Leave benefits. After this requirement has been
met I have the option to integrate my accrued sick or vacation leave with my Paid Family leave
benefit and elect to do so as follows:
I do / do not wish to utilize my accrued sick hours during my family and medical leave
(circle one)
I do / do not wish to utilize my accrued vacation hours during my family and medical leave
(circle one)
_____________________
Employee Signature
Date
__________________________
Supervisor Signature
Date
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