Request for Leave of Absence - LTU



Request for Non-FMLA Leave #3112

Instructions. Complete this form and submit it to your supervisor for review and approval. Forward the completed form to the Office of Human Resources.

Staff and Non-Academic Administrators Only/Leave Time Usage. Staff and Non-Academic Administrative employees are required to exhaust any available sick leave time as part of the approved leave period. After sick time is exhausted, employee may request vacation or personal leave time, so as to be paid for all or a portion of the leave. Note: All sick time and elected leave time must be applied before any disability income benefits may apply (for employee’s own medical-related illnesses).

Fitness-for-Duty Certification/Return to Work. Employees returning from medical leave of absence must present a fitness-for-duty certification from their treating health care provider to be restored to employment.

When a Non-FMLA leave ends, every reasonable effort will be made to return the employee to the same position, if it is available, or to a similar available position for which the employee is qualified. However, Lawrence Tech cannot guarantee reinstatement in all cases.

View Policies. To view leave and related policies, access the Employee Handbook at

Questions? Contact the Office of Human Resources at 248.204.2150 or via email at benefits@ltu.edu.

|Personal Information |

|Print Name (Last, First, Middle Initial): |Position: |

|      |      |

|Banner ID Number: |Home Phone: |

|      |      |

|Department Name: |Office Extension: |

|      |      |

|Type of Non-FMLA Leave: Medical* Military Orders Personal Leave |

|*For a Non-FMLA Medical Leave, also submit the Non-FMLA Medical Certification Form #3110. |

|Leave Period Taken: Consecutively Intermittently Reduced leave schedule |

|Last Day at Work |First Date of Leave |Last Date of Leave |Expected Return to Work Date |

|      |      |      |      |

|Explain reason for leave of absence (attach additional sheets of explanation, if necessary and/or military orders) :       |

| |

|Leave Time Usage (Staff and Non-Academic Administrators Only) |

|Dates Absent |Indicate Number of Days |

|Start Date |End Date |Vacation Time |Personal Time |Leave without Pay |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

Note: Your sick time and elected (vacation or personal) leave time will automatically be applied during the payroll process, except for during an intermittent leave. For an intermittent leave, please contact the Office of Human Resources for additional information.

Signatures

Employee signature: Date:

Supervisor’s Name:

Approval/Disapproval Supervisor’s Signature: Date:

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