Leave of Absence Request Form
Leave of Absence Request
* Per Policy: Employee must request a leave of absence at least two (2) weeks in advance. Leave is for up to 30 calendar days and must have the approval of management and human resources. One extension of up to an additional 30-days may be granted with prior HR approval to the original 30-day leaving ending period. No more than 60-days maximum of LOA will be allowed. If the leave is for medical reasons, the employee will be required to provide a doctor's certification for approval of the requested leave. Failure to return to work after the leave of absence will be considered job abandonment and the employee will be terminated.
**Upon return from a LOA, an employee will be returned to the position which she/he held prior to the LOA, if practicable.
***Employees will receive via email a fully executed copy showing the results of the request.
****Employees are required to pay for any insurance premiums PRIOR to starting the LOA and must pay for the amount due for the entire LOA period.