Employee Request for Leave Employee Name:
____________________________________________________
Home Address:
____________________________________________________ ____________________________________________________
Check One: Full-Time â–Ą Part-Time â–Ą Type of Leave Requested
X
Leave Start Date
Expected Return from Leave date
Employee Medical Family Medical Personal
Reason for Request: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Please check here if you are going on leave for the birth of a child and would like further information concerning accommodations offered under the 2009 Breastfeeding Promotion Act.
Employee Signature: _______________________________
Date: ____________
Management Approval: _____________________________
Date: ____________