Job Title: Hire Date:
Type of leave requested (if request is due to medical reasons, have your physician complete the "Physician's Statement" near bottom of page):
____ medical leave ____ pregnancy leave
____ family leave ____ military leave
____ other (explain):
Start date: Expected return date:
Do you want to use accrued vacation time before unpaid leave? Yes No
If yes, total number of accrued vacation hours or days requested:
LEAVE, IF GRANTED, MAY BE USED ONLY FOR THE PURPOSE DESCRIBED ABOVE. I understand that the use of leave for any other purpose will be grounds for disciplinary action including termination of employment. I understand I must return to work upon expiration of my leave of absence. I understand I must keep the office informed of a current address and telephone number of where I may be contacted.
Before returning from medical or pregnancy leave I will submit a health-care provider's verification of my fitness to return to work (including any limitations on the my ability to perform the essential duties of my job).
Employee signature:________________________________________ Date:____________
PHYSICIAN'S STATEMENT The above person is a patient in my care, and should be able to resume his/her duties on or about .
Telephone No.: _______________________
Physician's signature:_____________________________________ Date: _________
_____ Approved _____ Denied (reason):
Manager's signature:_____________________________________ Date:____________