Leave Of Absence Management Form
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CALIFORNIA STATE UNIVERSITY, DOMINGUEZ HILLS
Department of Human Resources
Leave of Absence Management
Employee Information
Name: _______________________________________________
Street Address: _______________________________________
City: ________________________________________________
State: ________
Zip Code: _______________
: __(____)_________________________
: __(____)________________________
Home Phone
Cell Phone
Period of Leave
I request a ___________________ leave of absence beginning on _______________ and ending on ______________.
(Full-time or half-time)
(e.g. 01/01/08)
(e.g. 01/01/08)
______________
________________
My last work day will be
. My anticipated return to work day will be
.
(e.g. 01/01/08)
(e.g. 01/01/08)
Purpose of Leave
(Please check all that apply)
1
Sick Leave (If exceeds 3 days, time will be counted towards your FML entitlement)*
1
Family Medical Leave (Must complete the FMLA Notice and Acknowledgement Form)
1
Pregnancy Disability Leave (Maximum of four months or 704 hours if used intermittently)*
1
Paid Maternity/Paternity/Adoption Leave (Must complete the Application Form)*
1
Organ Donor Leave Program (Must exhaust ALL sick leave credits)*
1
Military Leave
Pay While on Leave
(Please check all that apply)
Yes
No
1
1
I will be using my accrued sick leave
1
1
I would like to apply for Non-Industrial Disability (NDI)*
1
1
I will be using my accrued vacation leave
1
1
I will be using my CTO & Personal Holiday
1
1
I would like to apply for Catastrophic Leave Donations**
*All sick leave credits must be exhausted to receive NDI
*There is a seven calendar day waiting period before NDI benefit begins
**All leave credits must be exhausted to receive Catastrophic Leave Donations
I understand that it is my responsibility to inform my department of my intent to take a leave and the period in
which the leave will be for.
Employee Signature: ______________________________________
Date: ___________
For Benefits Use
Only:
_________
CBID:
______________________________
CC: Dept. Head
Created: May, 08
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