Leave Of Absence Request Form - City Of Sacramento
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1
2LEAVE OF ABSENCE REQUEST FORM
Part A - EMPLOYEE INFORMATION
1. Name (Last, First, MI)
4. Union
3. Dept ID
2. Employee ID
5. Department /Division Name
Part B- LEAVE INFORMATION
1. Leave Reason
9. If you are eligible for disability insurance
5. Current Leave Request
Attach supporting documentation
the City will automatically supplement
Start Date
End Date
Family Care
your disability insurance pay with City
pay (see reverse for more information).
Medical
Military
Please check box, if applicable
6. Expected Return
Date
Parental
I will NOT file a disability insurance
claim for this leave period.
Personal
Pregnancy Disability
7. Previous Leave
I do NOT want my disability insurance
2. Intermittent
Start Date
End Date
pay to be supplemented with my City
Yes
No
pay. I understand I will not receive pay
from the City during my leave.
3. Reduced Schedule
Yes
No
8. Please indicate the pay types you want used.
4. Is this an Extension?
Yes
No
EMPLOYEE: Please note important information on reverse side of this form!
I am aware of the Administrative Policy Instruction, and/or Civil Service Board
Employee Signature
Date
rules governing this leave. I am also aware of the provisions in the labor
agreement or Unrepresented Personnel Resolution covering my position
which pertains to this leave.
Part C - PERSONNEL ACTION / DEPARTMENT APPROVAL
1. Effective Date
2. Does the employee qualify for City Parental Pay or Pregnancy Disability Pay?
No
PAR
PGD
160 hours
80 hours
4. Department Authorization (Name, Title, Signature, Date)
3. PAR Processor (Name, Title, Signature, Date)
Approved
Denied at Department
Pending HR Approval
Date
Date
Part D - REMARKS
Part E - HR USE
Initials/Signature
Date
Division/Function
Director of Human Resources Signature (Required if Over 90 days)
E&C
A)
Leave Admin
B)
Date:
Leave Administration Policy
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