HTML Preview Personal Leave Request Form template page number 1.
Request for Leave of Absence: Personal Leave
I require a Personal Leave of Absence due to the following reasons:
Medical: If you are requesting a medical leave of absence but are not eligible for FMLA, you are required to submit a Certification of
Health Care Provider form. If your leave is approved, it will be counted against your FMLA entitlement. The Health Care Provider
form must be submitted only to the Human Resources Department.
Non-Medical: Please explain, e.g. family emergency, personal business, below.
FOR HR USE ONLY
Employee Signature & Date
DateName
University ID Email Address
Campus Mailing Address Campus Telephone
Home Mailing Address Home Telephone
Full Time Part Time
Status:
Employee Name
Immediate Supervisor
Signature & Date
Immediate
Supervisor Name
Department Head
Signature & Date
Department
Head Name
Approved PAF Received Denied & Reason for Denial:
Comments
HR Representative Signature and Date