Pregnancy Disability Leave Request Form printable pdf download

Pregnancy Disability Leave Request Form 09/09/15

Pregnancy Disability Leave Request Form

Employee Name: _____________________________

Preferred Phone: ___________________

Last Name

First Name

SSN#: _____________________

Regular work hours per week: ____40 ____ 31-34 ____ 20-30 ___Other

Days per week scheduled to work: ____M ____ T ____ W ____ TH ____FRI ____ SAT ____ SUN

In order to request a medical leave of absence, thoroughly complete each section below and follow the How to

Apply for a Leave of Absence. This form must be returned to the Office Manager, 30 days prior to your

first day of absence, or within 2 days of absence due to unforeseen circumstances.

PREGNANCY DISABILITY LEAVE

The Pregnancy Disability Leave of Absence policy allows an employee to be away from work, in full workweek

increments, on a reduced work schedule, or intermittently. This leave will run concurrent with any applicable

federal and/or state leave laws.

Employees may request to take a pregnancy disability leave of absence for any periods of actual disability caused by

pregnancy, childbirth or related medical condition, including time off needed for prenatal care, severe morning

sickness, doctor-ordered bed rest, and recovery from childbirth. Medical certification from the employee’s health

care provider will be required. A pregnancy disability leave of absence may be approved for absences up to 12

weeks with medical certification.

HOW TO APPLY FOR A LEAVE OF ABSENCE

1. Read the Pregnancy Disability Leave policy located in the Employee Handbook;

2. Complete this form in its entirety;

3. Obtain the Office Manager’s signature

Please note that you have not been approved for a leave of absence until you have received approval from the Office

Manager. Unauthorized absences may result in disciplinary actions, up to and including termination of employment.

ANSWER ALL QUESTIONS BELOW

A. ____ Yes ____ No

Are you requesting leave due to your own disability caused by pregnancy, childbirth or related medical

condition, including time off needed for prenatal care, severe morning sickness, doctor-ordered bed red, and

recovery from childbirth? If you answer “no” then you are not eligible for a Pregnancy Leave. Do not complete

this form.

B. ____ Yes ____ No

Are you requesting intermittent leave or a reduced leave schedule due to medical necessity? If “yes” provide the

Details of your proposed new work schedule. (i.e. M-F 8-12 for three weeks): __________________________

___________________________________________________________________________________________

C. ____ Yes ____ No

Are you requesting to utilize unused available Sick Leave? If “yes” how many hours? _________. Sick Leave

will then be paid in accordance with the Sick Leave Policy.

DATES OF PREGNANCY LEAVE REQUESTED

I request leave to begin on (1

work day of absence) ______

I will return to work on (1

returning work day) __________

Pregnancy Disability Leave Request Form

Related Articles

Related forms

Related Categories