Request for Time Off, LOA, Sick or FMLA

Employee Full Name

First NameLast Name

Today's date:

Today's date

Phone number where we can contact you if needed

Please enter a valid phone number.Format: (000) 000-0000.

Reason for Leave

Requesting the use of

Requested Start Date

Date

Return Date

Date

Requested reduced work schedule

Sick Leave is used only for actual illness and includes; MD appointments or family medical appointments, unexpected illness, preventive care such as physical or care of immediate family member. Must be employed 90 days to use accrued sick leave and use a minimum of 2 hours. A physician's note is required for illness, emergency room visit, hospitalization, clinic visits or family medical appointments. If you call in sick a supervisor MUST confirm the illness to request the use of accrued sick leave.

Paid leave using accrued sick hours or vacation can be substituted for the unpaid leave in accordance with the Family Medical Leave Act Policy. FMLA is for up to three months and must meet FMLA Requirements.

I understand that I am required to use accrued paid time off until leave concludes or accrued balance is depleted.

Employee Signature