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It collects request details such as date, department, employee identification, contact information, leave type (full, intermittent for FML, partial with pay), leave begin/end dates, last day worked, and expected return-to-work date. The form records reasons for leave, including FML medical condition and family medical leave options, NDI yes/no confirmation, and employee certification. 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Medical certification/supporting documentation is submitted to Human Resources.",{"name":116,"@type":107,"acceptedAnswer":117},"Who approves the leave and what happens in case of denial?",{"text":118,"@type":110},"An authorized administrator completes Section B with an approved yes/no decision and includes a reason for denial and recommendations when applicable. The Department of Human Resources completes Section C with the HR representative’s signature and final approval status.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},279755,1790056271,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},1374391974585,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","INSTRUCTIONS: Please complete request and submit to supervisor and appropriate administrator. For information on leaves, please contact the Department of Human Resources: (707)654-1146 .  \n\n| SECTION A: TO BE COMPLETED BY EMPLOYEE (PLEASE PRINT OR TYPE) |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Date of Request: | Department: |  |  |  | Classification: |\n| Employee ID: | Name (First, M, Last): |  |  |  | Phone Number: |\n| Address (include city, state, and zip code): |  |  |  |  |  |\n| Leave of Absence Request:\u003Cbr>􀂉 Full 􀂉 Intermittent(FML only) 􀂉 Partial Leave with Pay |  |  |  | Work Schedule: |  |\n| Leave Begin Date: | Leave End Date: |  | Last Day Physically Worked: |  | Expected Return to Work Date: |\n| REASON FOR LEAVE REQUEST\u003Cbr>Medical certification/supporting documentation for leave must be submitted directly to the Department of Human Resources. |  |  |  |  |  |\n| FAMILY MEDICAL LEAVE OF ABSENCE – FML\u003Cbr>☐ Serious Medical Condition of Employee\u003Cbr>☐ Serious Medical Condition of Family Member Specify Relationship:  \u003Cbr>☐ Employee’s Pregnancy ☐ Adoption\u003Cbr>☐ Placement of Foster Child with Employee ☐ Parental |  |  |  | OTHER LEAVES\u003Cbr>☐ Military Leave\u003Cbr>☐ Education Leave\u003Cbr>☐ Personal Leave (Please Explain):\u003Cbr>|  |\n| Check Yes or No for Non-Industrial Disability (NDI)– See NDI Section on the back of this form\u003Cbr>☐ Yes ☐ No |  |  |  |  |  |\n| I certify that all the facts are true and correct to the best of my knowledge. If my request for a leave of absence is approved, I understand that I must abide by all the terms and conditions of my leave of absence. If I am unable to return to work on the specified date, I am to notify the Department of Human Resources of the change. Failure to notify the Department of Human Resources may result in my being absent without authorization.\u003Cbr>Employee Signature   Date   |  |  |  |  |  |\n| SECTION B: TO BE COMPLETED BY AUTHORIZED ADMINISTRATOR |  |  |  |  |  |\n|  |  |  |  |  |  |\n| Department Administrator Name Signature Date\u003Cbr>Reason for Denial and Recommendation: |  |  |  |  |  |\n| Approved: ☐ Yes ☐ No |  | |  |  |  |\n\nSubmit Leave of Absence Request for to the Department of Human Resources  \n\n| SECTION C: TO BE COMPLETED BY THE DEPARTMENT OF HUMAN RESOURCES |  |  |  |\n| --- | --- | --- | --- |\n| Authorized HR Representative | Signature |  | Approved:\u003Cbr>☐ Yes ☐ No |\n|  |  | Date |  |","cbCaigTRrlKHDTp0","https://ap.wps.com/l/cbCaigTRrlKHDTp0","pdf",547184,"English","# SECTION A: TO BE COMPLETED BY EMPLOYEE\n## Request details\n## Reason for leave and FML options\n## Employee certification and signature\n# SECTION B: TO BE COMPLETED BY AUTHORIZED ADMINISTRATOR\n## Administrator decision and denial/recommendation\n# SECTION C: TO BE COMPLETED BY THE DEPARTMENT OF HUMAN RESOURCES\n## HR representative approval status","[{\"question\":\"What information must the employee provide in Section A?\",\"answer\":\"The employee completes request dates, department, employee ID and personal contact details, leave type, leave begin/end dates, last day physically worked, expected return-to-work date, and the reason for leave.\"},{\"question\":\"How is Family Medical Leave (FML) selected and documented?\",\"answer\":\"The form provides FML checkboxes for a serious medical condition of the employee or family member, and related categories such as pregnancy, adoption, foster placement, or parental leave. Medical certification/supporting documentation is submitted to Human Resources.\"},{\"question\":\"Who approves the leave and what happens in case of denial?\",\"answer\":\"An authorized administrator completes Section B with an approved yes/no decision and includes a reason for denial and recommendations when applicable. The Department of Human Resources completes Section C with the HR representative’s signature and final approval status.\"}]","Leave of Absence Letter Example Template 10 - Request Form | PDF",1789526727]