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LEAVE OF ABSENCE REQUEST
FOR DEPARTMENT USE ONLY: Personnel
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:
Initial Application
Amendment to LOA
that began on
_________________
Own Injury/Illness (not work-related)
Care for Injured/Ill Family Member
Pregnancy/Disability
Care for Newborn/Placed Child
Date of Birth/Placement _______________
Union Business
Work-Incurred Injury/Illness
Professional Development
Military Caregiver Leave
Qualifying Exigency Leave
Administrative
Military
Other (specify):
Requested start date
____________________
Anticipated return date:
____________________
Requested intermittent or reduced work schedules
Do you have UC medical insurance?
Yes No
Do you have UC dental insurance?
Yes No
Do you have UC optical insurance?
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
_______ Hours of accrued vacation
Begins on _______________ and ends on _______________
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)
Your request for leave is approved and
____ weeks ____ days ____ hours qualify as FM leave under FMLA
____ weeks ____ days ____ hours qualify as FML leave under CFRA
____ weeks ____ days ____ hours qualify as PDL leave under PDLL
____ weeks ____ days ____ hours qualify as (Specify)____________________
Begins on _______________ and ends on _______________
Begins on _______________ and ends on _______________
Begins on _______________ and ends on _______________
Begins on _______________ and ends on _______________
Begins on _______________ and ends on _______________
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
Extended Sick Leave
Vacation
Leave without pay
_______ hours to be applied
_______ hours to be applied
_______ hours to be applied
_______ hours to be applied
Begins on _______________ and ends on _______________
Begins on _______________ and ends on _______________
Begins on _______________ and ends on _______________
Begins on _______________ and ends on _______________
(Attach additional sheets if necessary)
DEPARTMENT SIGNATURE
NAME (PRINT)
SIGNATURE
DATE
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