Leave Of Absence Request Form PDF Details

In the complex landscape of employment, the Leave of Absence Request form plays a crucial role for both employees and employers. This document allows employees to formally request time away from work for various reasons, including medical conditions, family responsibilities under the Family and Medical Leave Act (FMLA), personal matters, or other unspecified reasons. The form requires clear information such as the employee's name, department, the type of leave requested, and the intended start and return dates. Additionally, it mandates an explanation for the leave, ensuring that the request is adequately documented and understood by all parties involved. The form also highlights important conditions that the employee must acknowledge by initialing: understanding the leave is generally unpaid unless specified by company policy, accepting the maximum durations for medical or personal leave (six months) and FMLA leave (twelve weeks), the requirement to submit a physician’s release if the leave is medical in nature, and the implications for job security dependent on the type of leave and the availability of the position upon intended return. This formalized process not only helps streamline administrative procedures but also affords protection and clarity to employees navigating through their rights and obligations while planning for a leave of absence.

QuestionAnswer
Form NameLeave of Absence Request Form
Form Length1 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out27 sec
Other namesprintable leave of absence form, leave of absence form template, leave of absence request form template, leave of absence form sample

Form Preview Example

LEAVE OF ABSENCE REQUEST FORM

Name:________________________________ Date: ___________________

Department: _____________________

Type of Leave Requested:

Medical Leave ( ), FMLA Leave ( ), Personal Leave ( ), Other ( ) Leave Start Date: __________________Return Date: ____________________

Reason for Leave:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Read carefully the following, and initial each blank to signify understanding.

________

I understand that my leave of absence is without pay, other than authorized

 

in the Leave of Absence Policy, and that the duration of any leave is at the

 

discretion of the department head.

Medical and personal leave may not

 

exceed six months; FMLA Leave cannot exceed twelve weeks.

________

I understand that I must return to work, or request an extension, by

 

___________ or I will be deemed to have voluntarily terminated my

 

employment on that date.

 

________ I understand that I must submit

a written physician’s release to the

 

Administrative Office in order to return to work from a Medical Leave of

 

Absence.

 

________ For other than FMLA Leave, I understand that my present position may not

be available either due to a need to fill the vacancy or due to a medical

condition related to my release.

 

__________________________________

_____________

Employee Signature

Date

_________________________________

______________

Department Head

Date

_________________________________

______________

Administrative Office

Date

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Jot down the data in I understand that I must return to, I understand that I must submit a, For other than FMLA Leave I, Employee Signature, Department Head, Administrative Office, Date, Date, and Date.

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Related Resources

  • Leave of Absence (LOA) - DGS.CA.gov

    Request “direct pay” forms from the Attendance Clerk to continue medical benefits and make direct payment to insurance(s) carrier(s). If requesting extension, ...

  • Formal Leave of Absence Request

    FORMAL LEAVE OF ABSENCE REQUEST. Office of Human Resources. DGS OHR 28 (Rev. 09/2019). REVIEW PAGE 2 FOR ADDITIONAL INFORMATION AND INSTRUCTIONS.

  • Request for Leave or Approved Absence - OPM

    Type of Leave/Absence ... Certification: I hereby request leave/approved absence from duty as ... if required) and that falsification on this form may.

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