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Type of leave requested (Please review the Employee Handbook for policy guidelines on the following types of leave): Sick Leave (if for other than self, please indicate) Pregnancy Disability Leave (CA only. If in NV on KY, please check Sick Leave.) Personal Leave Jury Duty Bereavement Leave Military Leave Vacation Other time off request (explain) Reason for leave/absence:
(Please attach an additional sheet of explanation, if necessary, for Personal Leave. Attach a copy of military orders for Military Leave and Jury Summons for Jury Duty Leave.)
Beginning date of leave: Expected date of return: Do you want to use accrued vacation time? If yes, current number of hours accrued to date: TOTAL number of hours and days to use: Will you have enough hours to cover your entire leave? If no, please explain: Pay period in which time- off taken:
Yes Yes No No
Employees requesting Sick leave longer than three days or Pregnancy Disability Leave must attach a health-care provider's statement verifying the need for leave and its beginning and expected ending dates. In addition, if leave is requested under the Family Medical Leave Act, you must submit a completed Certification of Health Care Provider form (DOL form WH-380) in order to determine eligibility for this leave. This form may be obtained by contacting the Human Resources Department. Any changes in this information should be promptly reported. Employees returning from a Sick Leave that is 3 business days or longer; or Pregnancy Disability Leave must submit a health-care provider's verification of their fitness to return to work (including any limitations on the employee's ability to perform the essential duties of the job).
Employee signature: Manager's approval: Payroll sign-off and comments:
Date: Date: Date: ______________