Leave of Absence LOC Form

LEAVE OF ABSENCE LOC FORM

Use this Leave of Absence LOC Form to request and document a leave of absence. Completion of this form initiates formal review by Human Resources. Provision of supporting documentation (medical certification, military orders, or other substantiating evidence) may be required to establish eligibility and continued job protection. Submission of false or misleading information may result in disciplinary action up to and including termination.

Personal Information

Position Information

Leave Details

Type of Leave (check all that apply):

Health Care Provider / Documentation

If leave is for a health condition, provide provider information and attach certification. The employer may require completion of a medical certification form and may seek clarification or second opinions at employer expense.

Pay, Benefits, and Job Status

Payroll status during leave:

Benefits continuation: Employee acknowledges that benefit eligibility and premiums during leave will be administered in accordance with applicable policy and law. Employee is responsible for timely payment of any employee contributions required to maintain benefits.

Employee Acknowledgements and Authorizations

By signing below, I certify that the information provided on this form and in any supporting documentation is true, complete, and accurate to the best of my knowledge. I understand that leave approval is contingent upon compliance with company policies and applicable law and may be rescinded if eligibility cannot be established. I further acknowledge that:

• I authorize the employer to communicate with my health care provider(s) to the extent necessary to verify the medical need for leave, subject to applicable privacy laws, and to seek clarification or a second opinion if required.
• I agree to provide periodic status updates and to notify Human Resources as soon as practicable of any change in my expected return date.
• I understand that I may be required to provide a fitness-for-duty certification prior to returning to work.
• Falsification, omission, or misrepresentation of facts in connection with this request may result in denial of leave and disciplinary action up to and including termination of employment.

At-Will Employment Statement: Nothing in this form alters the at-will nature of employment where applicable. Either the employee or the employer may terminate the employment relationship at any time, with or without cause, unless otherwise provided in a valid written agreement.

Equal Opportunity Statement: This employer provides equal employment opportunities to all employees and applicants without regard to protected characteristics. Leave administration will be performed in a non-discriminatory manner consistent with applicable law and policy.

Employment History (for Personnel File)

Employer 1

Employer 2

Education

References (Professional)

Reference 1

Reference 2

Reference 3

Applicant Certification and Authorization

I certify that all information provided on this form and in any attachments is true and complete. I authorize the employer and its designated agents to obtain and review records and documentation necessary to verify my request for leave, including medical records and other relevant documentation. I understand that any protected health information obtained by the employer will be treated in accordance with applicable privacy laws and will be used only for leave administration and related employment decisions.

I further acknowledge that I am responsible for informing Human Resources of any changes to the information provided, and that I must comply with return-to-work procedures, including providing a fitness-for-duty certification if required.

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