Honorhealth Leave Of Absence Request Form For Medical, Maternity, Family Or Military Page 2
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1
2
3LEAVE OF ABSENCE REQUEST
For Medical Leave or Family Care Leave
Instructions – (1) This form should be completed by the staff member (or their designated personal representative) and
returned to Employee Benefits as soon as possible. (2) It is the staff member’s responsibility to ensure that Employee
Benefits receives all required completed forms. DO NOT RETURN COMPLETED FORMS TO YOUR DEPARTMENT.
1 – E
S
I
ECTION
MPLOYEE
NFORMATION
Name (printed)
Employee #
Address
City
State
Zip Code
Wk Phone
Hm Phone
Cell Phone
May we communicate with you using your personal email?
No
Yes
Email:
2 – J
S
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ECTION
OB
NFORMATION
Dept Mgr
Ext
Dept Supervisor
Ext
3 – R
S
ECTION
EASON FOR REQUESTING LEAVE
I am requesting leave for the following reason:
My own health condition – provide dates below(if applicable) Is the condition work related: Yes
No
Date of surgery/illness:
Date of in-patient admission
Birth of my child; to care for my newborn child:
Anticipated due date:
Do you plan to be off
6 weeks or
12 weeks?
Placement of a child with me for adoption or foster care
Care for a family member with a serious health condition
Relationship of family member to me:
Military
Qualifying exigency because family member is on active duty or has been called to active duty
Relationship of family member to me:
Care for a family member who is a member of the Armed Forces and is undergoing medical treatment or
recuperating from a serious injury or illness incurred while on active duty
4 – D
– D
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ECTION
URATION OF
EAVE
ATES ARE REQUIRED TO BE PROVIDED
Date Leave Expected to Begin:
Date Leave Expected to End:
Will this leave be for a continuous period or intermittently?
Continuous
Intermittently/Reduced Schedule
If intermittent or reduced-leave schedule, please provide the estimated duration of scheduled leave:
5 – S
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IGNATURE
I understand that all leave and duration are based on the medical certifications provided by my doctor. Failure to comply with any
policies or procedures associated with my leave may result in denial of my leave and/or termination of my employment. I further
understand that it is my responsibility to provide supporting documentation to Employee Benefits upon request.
Staff Member Signature
Date
X
Mail or fax completed documents to:
HonorHealth, Employee Benefits
8125 N Hayden Rd, Scottsdale, AZ 85258
Fax: (480) 882-5802 /
Email:
Rev January 2013- Medical, Family, Military
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