Updated Leave of Absence Form

Updated Leave of Absence Form

Use this form to request or update a leave of absence. Complete all applicable sections and attach supporting documentation. Submission of this form constitutes a written request for leave and authorizes the employer to obtain necessary verification from health care providers or other third parties as described below.

Personal Information

Employee Name:

Employee ID:     Department:

Position Information

Hire Date:     FTE Status:     Salary (annual):

Leave Request Details

Type of Leave (check all that apply):

Medical leave (self)     Family/Parental leave     Military leave
Personal leave     Bereavement     Jury duty     Other:

Requested Leave Start Date:     Expected Return Date:

Is leave intermittent or reduced schedule? Yes No     If yes, describe frequency/schedule:

Supporting Documentation

Required or provided documentation (check all that apply):

Medical certification from provider     Doctor's note / treatment plan
Birth certificate / placement papers     Military orders / documentation
Jury summons / court documentation     Other:

Pay and Benefits During Leave

Employee elects to use accrued paid time while on leave: Yes No

If paid leave is not available, employee requests unpaid leave: Yes No

Benefits continuation requested (employee responsible for applicable contributions): Yes No

Employment History (Most Recent Employers)

Employer 1 - Company Name

Employer 2 - Company Name

Education

References (Professional)

Legal Disclosures and Notices

At-Will Employment: I understand that my employment is at-will, unless I have a separate written employment agreement signed by an authorized company representative. Submission of this leave request does not alter the at-will nature of employment.

Equal Opportunity: The company provides equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, or other protected characteristics. Leave determinations will be made in accordance with applicable law and company policy.

Employee Certification and Authorization

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation may be cause for denial of leave, disciplinary action, or termination.

I authorize the company to contact health care providers, insurers, or other relevant third parties to obtain and verify information necessary to evaluate this leave request, including medical certification and records. I further authorize the release of medical information to the company for the limited purpose of assessing my leave, accommodations, return-to-work status, and continuation of benefits.

I acknowledge my responsibility to provide timely updates regarding the status of my leave and my anticipated return-to-work date. I understand that failure to return on the agreed date or to provide required documentation may result in termination of employment or other action permitted by law and company policy.

HR Use Only

Approved     Denied     Conditions/Notes:

Approved Leave Start Date:     Approved Return Date:

Benefit Continuation: Continue benefits     Do not continue benefits

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