Request For Formal Leave Of Absence Form - California State University Fullerton
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REQUEST FOR FORMAL LEAVE
OF ABSENCE
A. EMPLOYEE INFORMATON
Faculty
Staff/Management
Department
Employee ID
First Name
Last Name
Date Initiated
Contact Information While on Leave:
Address
City
State
Zip
Phone Number
CA
B. LEAVE OF ABSENCE INFORMATION
(please complete all sections)
Action
Leave Type
Leave Time Base
Leave Credits
Will you be using
Pregnancy Disability**
New
Medical*
Full
leave credits?
Change*
FML Self
Parental**
Partial (For partial, provide the
Yes
No
Faculty:
Leave Ext. Date:
FML Family
number of hours or WTU
30 paid days
Relationship:
Please check all credits
absent per week: _____)
40% paid reduction
that will be used:
Early Return Date:
Intermittent
Sick
Personal (Unpaid)
Military
(attach orders)
(Employees not taking
Vacation
Professional (Unpaid)
consecutive leave, attach a
Organ Donor Program*
Cancel*
Personal Holiday
work schedule )
(Attach description of activity)
*Attach copy of
*Medical certification required
CTO
original leave form
**Attach evidence of due date/birth/adoption
Non-Industrial Disability Insurance (NDI)
Dates for Leave
(Please specify month, day, and year)
Date From:
Yes
No
Will you be applying for NDI?
If yes, you must exhaust your sick leave balance. If you
Date Through and Including:
choose to use your vacation, you must exhaust your
Yes
No
balance. Do you elect to use your vacation credits?
Yes
No
Will you be applying for Catastrophic Leave?
Expected Return to Work Date:
If yes, you must exhaust all leave, credits.
C. EMPLOYEE CERTIFICATION AND ACKNOWLEDGEMENT OF LEAVE DATES
This is to certify that the information provided here is accurate to the best of my knowledge
Date
Employee's Signature
D. RECOMMENDATIONS
(as appropriate per division)
Position
Printed Name
Signature
Recommended?
if not recommended, please
attach justification
Chair / Director:
Yes
No
Dean / Administrator:
Yes
No
Vice President / President:
Yes
No
(if applicable)
FORWARD COMPLETED FORM TO PAYROLL, BENEFITS & RETIREMENT SERVICES (CP770) FOR PROCESSING
FOR HUMAN RESOURCES USE ONLY:
Vice President HRDI:
Yes
No
Employee Details:
Review Details:
Comments:
Type:
Approved
Denied
Employee Class:
Hire Date:
Reviewed by:
SCO Position #:
FTE:
Forwarded To:
Empl Rcd:
CBID:
Date Forwarded:
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