Leave Of Absence Request Form
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FOR DEPARTMENT USE ONLY: Personnel
LEAVE OF ABSENCE REQUEST
Program or Collective Bargaining Agreement:
SECTION I – TO BE COMPLETED BY THE EMPLOYEE
EMPLOYEE'S NAME
TELEPHONE
CAMPUS
DEPARTMENT
TITLE
EMPLOYEE ID
Reason for Leave of Absence:
Own Injury/Illness (not work-related)
Union Business
Administrative
Initial Application
Care for Injured/Ill Family Member
Work-Incurred Injury/Illness
Military
Amendment to LOA
Pregnancy/Disability
Professional Development
Other (specify):
that began on
Care for Newborn/Placed Child
Military Caregiver Leave
_________________
Date of Birth/Placement _______________
Qualifying Exigency Leave
Requested start date
Requested intermittent or reduced work schedules
____________________
Anticipated return date:
____________________
Do you have UC medical insurance?
Do you have UC dental insurance?
Do you have UC optical insurance?
Yes
No
Yes
No
Yes
No
Have you or will you be filing a University Disability Insurance claim?
Yes
No
A leave of absence is normally leave without pay. Paid leave (accrued sick leave or vacation) may be substituted for all or a portion of the
unpaid leave in accordance with appropriate policies/contracts.
I wish to use paid leave as indicated below: (attach additional sheets if necessary)
(MM/DD/YYYY)
(MM/DD/YYYY)
_______ Hours of accrued sick
Begins on _______________ and ends on _______________
_______ Hours of accrued vacation
Begins on _______________ and ends on _______________
EMPLOYEE'S SIGNATURE:
DATE:
TELEPHONE:
SECTION II – TO BE COMPLETED BY THE UNIVERSITY
APPROVAL/DENIAL OF LEAVE REQUEST
(MM/DD/YYYY)
(MM/DD/YYYY)
Begins on _______________ and ends on _______________
Your request for leave is approved and
Begins on _______________ and ends on _______________
____ weeks ____ days ____ hours qualify as FM leave under FMLA
Begins on _______________ and ends on _______________
____ weeks ____ days ____ hours qualify as FML leave under CFRA
Begins on _______________ and ends on _______________
____ weeks ____ days ____ hours qualify as PDL leave under PDLL
Begins on _______________ and ends on _______________
____ weeks ____ days ____ hours qualify as (Specify)____________________
Family and Medical Leave
Your request for FML is not approved for the reasons set forth on the Designation Notice.
Other Leaves
Your requested leave is not approved for the following reason(s):
___________________________________________________________________________________________________________________
PAY STATUS DURING LEAVE
(MM/DD/YYYY)
(MM/DD/YYYY)
Sick Leave
_______ hours to be applied
Begins on _______________ and ends on _______________
Extended Sick Leave
_______ hours to be applied
Begins on _______________ and ends on _______________
Vacation
_______ hours to be applied
Begins on _______________ and ends on _______________
Leave without pay
_______ hours to be applied
Begins on _______________ and ends on _______________
(Attach additional sheets if necessary)
DEPARTMENT SIGNATURE
NAME (PRINT)
SIGNATURE
DATE
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Parent category: Business