Employee Leave of Absence Package

Employee Leave of Absence Package

Employee Name:   Employee ID:

Personal Information

Position Information

Reporting Manager:   Hire Date:

Leave Request Details

Leave Type (check all applicable): FMLA Medical Leave Personal Leave Parental Leave Bereavement Military Leave

Intermittent Leave Requested: Yes    No

Medical Certification / Provider Information

I authorize the release of medical information as necessary for leave administration: Yes    No

Benefits, Pay, and Job Protection

Use of accrued paid leave during absence: Use accrued paid leave No paid leave

Employee understands that continued benefits, job protection, and reinstatement are subject to applicable law, eligibility, and employer policy. Employee agrees to provide required certifications and additional documentation upon request.

Acknowledgment of Policies and Employee Certifications

At-Will Employment: Employee acknowledges that employment is at-will and that this leave request does not alter the at-will relationship unless otherwise set forth in a separate written agreement signed by both parties.

Equal Employment Opportunity: The employer prohibits discrimination and retaliation in employment and leave administration. Leave decisions will be made in accordance with applicable law and employer policy.

Applicant Certification: I certify that all information provided in this form and any attachments is true, accurate, and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation may result in denial of leave and/or disciplinary action up to and including termination.

Authorization to Contact and Verify: I authorize the employer and its designated agents to contact health care providers, previous employers, and other parties as necessary to verify information related to this leave request, to determine eligibility, and to administer benefits. I further authorize release of relevant records for these purposes.

Background Check Consent: For purposes of verifying employment eligibility or previous employment where required, I consent to any background checks required by the employer: Yes    No

Employment History (for verification)

Education

Professional References

Employer Use Only (To be completed by HR)

Leave Approved: Yes    No

Where required by law, the employee will be notified of rights and obligations related to job restoration, benefit continuation, and any certification requirements. Employee must provide requested documentation within timelines specified by employer policy.

Employee Certifications and Authorizations

By signing below, Employee certifies the truthfulness of the information provided, authorizes verification of employment and medical information as needed to process this request, and acknowledges that failure to comply with documentation requests may result in delay or denial of leave and potential disciplinary action.

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