Request For Formal Leave Of Absence Form - California State University Fullerton (Page 8 of 18) in pdf

Request For Formal Leave Of Absence Form - California State University Fullerton Page 8

Signature of Health Care Provider

Date

PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT

If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29

U.S.C. § 2616; 29 C.F.R. § 825.500.Persons are not required to respond to this collection of information unless it

displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 20

minutes for respondents to complete this collection of information, including the time for reviewing instructions,

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the

collection of information. If you have any comments regarding this burden estimate or any other aspect of this

collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and

Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.

DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.

Request For Formal Leave Of Absence Form - California State University Fullerton Page 8