Archdiocese Of Los Angeles Family And Medical Leave Forms Page 10
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13Archdiocese of Los Angeles
Form A
Leave of Absence Request
Please read the attached Archdiocesan Leave of Absence Policy. 1) Complete all sections of this form and give it to
your supervisor, for signature, along with sufficient certification for the leave, (i.e., doctor’s note). 2) Please bring
the leave request and certification to the appropriate administrator (i.e., Pastor, Principal, or Human Resources for
ACC/Cemeteries employees) for review and approval.
Employee Name: _________________________
Department: _____________________________
Home Phone: ___________________________
Cell Phone _____________________________
Beginning date of absence: _________________
Last date of absence: _____________________
REASON FOR LEAVE REQUEST
I am requesting:
___
Family and Medical Leave (FMLA) for:
___
The birth of a child, ___ placement of a child with me for adoption or foster care.
----- Pregnancy Disability Leave
___ Family Care Leave
___
My own serious health condition.
___
To care for my ___ spouse, ___ child, ___ legally domiciled adult or ___ parent due to his/her
serious health condition.
___
Because of a qualifying exigency since my___ spouse, ___ son, ___ daughter, or ___ parent is
on active duty status in support of a contingency operation as a member of the National Guard or
Reserves.
___
Because I am the ___ spouse, ___ son or daughter, parent or ___ next of kin of a covered
servicemember or eligible veteran with a serious illness or injury who requires my care.
___
Personal Leave
Reason:___________________________________________________
___
Military Leave
___
Military Spouse Leave
___
Workers’ Compensation Leave
ACKNOWLEDGEMENT
I have read and understand the attached Archdiocesan Leave of Absence policy. I understand that if leave eligibility
requirements are met and the leave is approved, it is my responsibility to keep my supervisor and appropriate administrator ( i.e.,
Pastor, Principal, or Human Resources for ACC/Cemeteries employees) informed regarding the status of my leave. I also
understand it is my responsibility to pay required insurance premiums during my leave as stated in the attached leave policy.
_____________________________________________________________________
Employee’s Signature
Date
______________________________________________________________________
Supervisor’s/Department Head's Signature
Date
______________________________________________________________________
Administrator’s/Human Resources Representative’s Signature
Date
Revised 2013
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