LEAVE OF ABSENCE REQUEST FORM
Part A - EMPLOYEE INFORMATION
1. Name (Last, First, MI)
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
your disability insurance pay with City
pay (see reverse for more information).
Please check box, if applicable
6. Expected Return
I will NOT file a disability insurance
claim for this leave period.
7. Previous Leave
I do NOT want my disability insurance
pay to be supplemented with my City
pay. I understand I will not receive pay
from the City during my leave.
3. Reduced Schedule
8. Please indicate the pay types you want used.
4. Is this an Extension?
EMPLOYEE: Please note important information on reverse side of this form!
I am aware of the Administrative Policy Instruction, and/or Civil Service Board
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?
4. Department Authorization (Name, Title, Signature, Date)
3. PAR Processor (Name, Title, Signature, Date)
Denied at Department
Pending HR Approval
Part D - REMARKS
Part E - HR USE
Director of Human Resources Signature (Required if Over 90 days)
Leave Administration Policy
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