University of Puget Sound
Leave of Absence Request Form
Staff Member Name (please print clearly) __________________________________________________
Department ________________________________
Immediate Supervisor ____________________
Campus Phone ______________________________
Work Email _____________________________
Home Address (Street/City/State/Zip) _____________________________________________________
Home/Cell Phone ____________________________
Type of Leave of Absence:
☐ New Request
Personal Email __________________________
☐ Extension Request
Check Which Leave Applies:
☐ Family Medical Leave (FMLA)
☐ Personal Leave
☐ Disability Leave
☐ Military Leave
☐ Other (Please explain): _____________________________________________________
Anticipated Dates of Leave (mm/dd/yyyy): From ____________________
To ____________________
Brief Narrative of Request (including reason):
Did you purchase short-term disability coverage?
☐ YES
☐ NO
I certify that the information contained on this form and any supporting documentation is true and
accurate to the best of my knowledge and is in accordance with the Staff Policies and Procedures
Manual. I understand that it is my responsibility to pay for the employee portion of my current benefits
if I exhaust my leave benefits, which can be paid by personal check, cashier’s check or ACH.
Staff Member Signature ______________________________________
I recommend that this leave be: ☐Approved
Comments:
☐Denied
Date _______________
☐Approved Conditionally
Immediate Supervisor (print name) ________________________________________________________
Supervisor’s Signature ______________________________________
Date _____________________
Please return this form and any supporting documents to CMB #1064 or in person at Howarth 016 or mail to
University of Puget Sound Human Resources, 1500 N Warner #1064, Tacoma, WA 98416-1064.
If you have questions or need assistance, please contact HR at 253.879.3369 or hr@pugetsound.edu.