REQUEST FOR PERSONAL LEAVE OF ABSENCE



REQUEST FOR PERSONAL LEAVE OF ABSENCE(Note: This leave is NOT approved until signed by the Director and Labor Relations)Employee’s Name: FORMTEXT ?????Department and Badge: FORMTEXT ?????MY ID: FORMTEXT ?????Employee Phone Number: FORMTEXT ?????Employee Email Address: FORMTEXT ?????Dates of Requested Leave: FORMTEXT ?????Reason for Leave (be specific, do not say personal business): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Employee’s Signature: FORMTEXT ?????Date Signed: FORMTEXT ?????This request is to be submitted to your department or Operations Administration at least 5 days prior to the first day of your requested leave.DO NOT WRITE BELOW THIS LINE.Anniversary Date: FORMTEXT ?????Available Vacation Hours: FORMTEXT ?????Comments FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Craft Superintendent ApprovalFOR OPERATIONS USE ONLY FORMCHECKBOX Approved FORMCHECKBOX DeniedDirector’s SignatureReason For Denial: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Date: FORMTEXT ????? FORMCHECKBOX Approved FORMCHECKBOX DeniedLabor Relations SignatureReason For Denial: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NOTE: Page 2 must be filled out or the request is incomplete.ddYou must indicate the specific reason for the leave of absence from the choices below: FORMCHECKBOX 1. I have been diagnosed, quarantined, recommended for quarantine by my health care provider, or experiencing symptoms of COVID-19 and seeking a diagnosis (provide medical documentation to support this request); FORMCHECKBOX 2. I have a member of my household, or I am providing care to a member of my household or a family member, who has been diagnosed with COVID-19 (provide the name of the person in your household or family member and date of diagnosis):Family Member Name: ____________________________________Date of Diagnosis: __________________ FORMCHECKBOX 3. I am the primary caregiver for child(ren) or a member of household who is unable to attend school or daycare that is closed because of COVID-19 (provide the name of the child(ren) or household member, their age, and school/daycare they attend):Child’s Name _______________________________________ Age __________________Child’s Name _______________________________________ Age __________________Child’s Name _______________________________________ Age __________________Child’s Name _______________________________________ Age __________________Child’s Name _______________________________________ Age __________________Name of School/Daycare: ____________________________________ Daycare Phone No.: ____________________________ FORMCHECKBOX 4. I am the breadwinner or major support for my household because the head of my household died from COVID-19 (provide obituary or letter from the funeral home with the name and date of death of the deceased).By my signature on this document, I attest that the foregoing is true and correct.? If it is determined that this form has been falsified, I may be subject to disciplinary action, up to and including termination. ................
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