Looking for a Oregon Legal Forms And Templates? Download it for free!

EMPLOYEE LEAVE REQUEST

♦ Employees subject to FLSA shall complete this form before leave is taken and ensure leave has been

approved.

♦ In the event of an unplanned absence, the employee shall complete the form immediately upon

return to duty.

♦ FLSA-exempt employees shall complete this form only for absences which are or may be FMLA/OFLA

qualifying (see reverse for qualifying criteria).

Last Name (please print)

First

M.I.

Functional Unit / Institution:

Executive Service

Management Service

Represented (Name of Labor Organization)

I request

hours (total) leave from official duty for the following reason(s):

BEGINNING on

ENDING on

(Date)

(Hour)

(Check AM/PM)

(Date)

(Hour)

(Check AM/PM)

I request that my leave be charged as follows: (Please indicate the number of hours for each type of leave requested in the space provided.)

Vacation

Sick Leave

Personal Leave

Comp Time

Military Leave

Leave Without Pay

Bereavement Leave (Relationship)

Other

(Specify Type of Other Leave)

If this leave is to care for a SERIOUS HEALTH CONDITION or a SICK CHILD, or for PARENTAL LEAVE, check the appropriate

spaces in the boxed area below: (See reverse for explanation of a serious health condition and FMLA/OFLA leave.)

 You must give 30 days advance notice unless an emergency exists.

Your serious health condition (see definition on back) .................................................................................................... FMLA, OFLA

Family member (son/daughter, parent, legal spouse) with a serious health condition (see definition on back) ............... FMLA, OFLA

Parent-in-law, grandparent, grandchild or same-sex domestic partner with a serious health condition (see definition on back) OFLA

Sick child who does not have a serious health condition, but requires home care ..................................................................... OFLA

Pregnancy (includes prenatal care, childbirth, and recovery) ........................................................................................... FMLA, OFLA

Care for a newborn, newly adopted, or newly placed foster child under age 18, unless incapable of self-care due to disability ............... FMLA, OFLA

Is this a previously approved FMLA/OFLA qualifying condition?

Yes

Do you have a spouse who works for the State of Oregon who is also requesting time off?

Yes

If yes, name of spouse and Agency where employed.

If approved for FMLA/OFLA, you must attempt to schedule leave to be as least disruptive to the employer.

Medical certification and/or fitness-for-duty certification may be required. (For sick child leave, medical certification may be required after

three days of leave.)

FMLA/OFLA Coordinators approve FMLA/OFLA Leave.

Supervisor signature does not guarantee FMLA/OFLA approval.

Employee Signature

Date