Leave of Absence Request Form

A leave of absence is available in certain circumstances as described in Promise’s Personnel Policies section 15, Leave of Absences. Employees who meet the eligibility criteria for a leave of absence must complete this form at least 30 days prior to the commencement of leave or as soon as practicable in the event of an unforeseeable absence. Please note:
•	All leaves of absence must be approved in advance by human resources (HR). 
•	If the dates of requested leave change, a new leave of absence request form must be submitted for approval. 
•	Employees on a leave of absence are responsible for payment of insurance premiums as agreed upon with HR prior to the commencement of leave. 
•	Employees returning from a leave of absence must contact HR at least one week in advance of the projected return date.
•	Please note that if you are requesting a Family Medical Leave or a Medical Leave, a Certification of Health Provider form must be submitted in order to determine eligibility.
To be completed by the employee:

Date of request: ______________   	Employee name: _______________________ 	
Department: _________________	Job title: _____________________________
Date of hire: _________________
Employee status:  ( ) Exempt   ( ) Nonexempt   ( ) Full time   ( ) Part time
Leave Category (please check appropriate bullet):
o	Family Medical Leave (for ex. One’s own serious health condition or to care for an immediate family members serious health condition)
o	Medical Leave (if Family Medical Leave does not apply)
o	Leave without Pay (if Family Medical Leave and Medical Leave do not apply)
o	Military Leave
Leave Type (please check appropriate bullet):
o	Continuous leave dates (mm/dd/yy): ____________ to ____________.
o	Intermittent leave (when there is not a need to be out of work on a continual basis but days are needed on an ongoing basis)
Reason for the leave of absence: ___________________________________________________________________
I have read and fully understand the information contained in Promise’s leave of absence policy.

________________________________________      _______________
Employee signature                                                      Date

To be completed by HR:

Leave request is: ____ Approved  	____ Not approved
If not approved, provide an explanation: __________________________________
__________________________________________________________________
Leave Type Approved:
o	Family Medical
o	Medical
o	Leave without Pay
o	Military
HR employee signature: _____________________	 Date: ____________________
Employee’s last day worked: __________ 	Employee’s return-to-work date: __________