Request for Medical Leave of Absence
Name
Date
Title
I hereby request a medical leave of absence as follows:
Beginning Date
Ending Date
Purpose of Leave:
Birth of child and to care for new-born child.
Employee's serious health condition which makes employee unable to perform the functions of employee's job.
Placement of child for adoption or foster care, and to care for adopted child or child in foster care.
The care of spouse, child or parent with a serious health condition. Relationship:
I understand upon receipt of this request the Human Resource Office will provide me with additional information and the additional
required forms that will need completed.
Print Form
Employee's Signature
Date:
Human Resource Office Use Only
Approved
Human Resource Director's Signature
Denied
Date