REQUEST FOR TIME OFF Employee Name:__________________________________ File #:____________________ Location:_________________________
Department:_______________________
EMPLOYEE SECTION Please check off which leave is applicable: ( ( ( ( ( (
) Bereavement : Relationship:____________ ) Jury Duty ) Personal Emergency Day ) Lieu Time ) Seminar (off site) ) Vacation □ Include with Regular Cheque
( ( ( ( (
) Float ) Personal Day ) Stat: Stat Name _________________ ) Sick Day ) Birthday □ Actual Birthday: ________________
□ Advance Cheque Required (only as applicable by collective agreement)
( ) Paid Start Date: ____________________
( ) Unpaid
( ( ( ( ( ( ( ( (
) Maternity Leave ) Parental Leave ) Sick Leave/ Weekly Indemnity ) Long Term Disability (LTD) ) Personal Leave: Days ______________ ) Family Medical Leave ) Educational Leave ) Union Leave ) Other ______________________
( ) Documentation Provided
End Date: _____________________
Total # of Days: ________________
Please circle date(s) of leave below
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For Maternity Leave, Parental Leave, Sick Leave/Weekly Indemnity, LTD, Personal Leave,
Family Medical Leave, Educational Leave, Union Leave, the following will apply: Supporting Documentation Please ensure that you submit any required supporting documents to your Manager as soon as possible. These documents are required for the processing of your Leave of Absence Request. If the documentation is not received, your leave of absence request will be delayed or not processed. It is your responsibility to complete your leave of absence request by submitting the required documentation as per the direction of your manager, or collective agreement, or company policies. Please note that your Manager can request supporting documentation for any leave (which may not be listed above) and the same expectations apply. Extended Health Benefit Continuance Benefits will be paid only to the end of the month in which your leave of absence commences. To continue with your extended health and dental (if applicable) coverage, you must provide post-dated cheques in advance covering the full amount of your portion of the premiums for each month of absence. If post-dated cheques are not received by the first day of your leave, your benefits will be suspended during your approved leave. Please refer to your paystub for the exact amount of your benefit premium per month. Please note that Life Insurance and LTD (if applicable) is mandatory and must continue during your leave. Top-Up If you are eligible for a top-up payment, you must submit copies of your EI stubs during the course of your leave. If you do not provide this documentation during your leave, you will not receive top-up after you return from your leave of absence. Return to Work It is your responsibility to provide your manager with a minimum of four (4) weeks notice (as applicable or as indicated in your collective agreement) to confirm your return to work date. Any extensions of a Leave of Absence must be approved by your Manager or designate prior to your original Return to Work date.
Employee Signature: ________________________________
Date: ____________________________
MANAGER SECTION
( ) Approved ( ) Documentation Provided
( ) Denied: (Explain)_____________________________________ ( ) Leave of Absence Benefits Policy given to employee
Dept. Head Approval: _____________________________________Date: ____________________________ Director of Administration Approval: ______________________________ Date: ____________________________ Client Care Specialist Approval: _______________________
Date: ____________________________
(PHC Front Line Staff) PHC STAFF ONLY Event Planner - scheduling Director of Ed - approval Manager - processing pg 2 of 2