WASHINGTON COUNTY REQUEST FOR LEAVE FORM

WASHINGTON COUNTY
REQUEST FOR LEAVE FORM
Employee___________________________________ Date__________________
I am hereby requesting the following leave, reduced work schedule, and/or intermittent leave
hours as follows:
Annual Leave:
Sick Leave:
For
For
Vacation
Tardy
Personal Illness, Disability
Medical Appointment Self
Medical Appointment, Family
Family Illness
Death
Maternity/Paternity
Other________________
Leave without pay _____________________________________________________
_______________________________________________________________________
Comp Time
Floating Holiday
Jury Duty
Workers’ Compensation
FMLA Requested (fill in bottom part of page if this block is checked)
Date(s) and/or time of leave requested from ____________________________ to
____________________________. Total number of hours requested ____________.
_________________________________
Employee’s Signature
_________________________________
Supervisor or Department Head Signature
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FMLA NOTIFICATION
Under the Family Medical Leave Act, eligible employees are entitled to 12 weeks of jobprotected, unpaid leave during a 12 month period for one or more of the following reasons:
 Birth or adoption of a son or daughter of the employee or placement of a child with the
employee for foster care
 Need for the employee to care for a spouse, child or parent with a serious health
condition
 The employee’s own serious health condition
The FMLA was amended to add Qualifying Exigency Leave and Military Caregiver leave. More
information on FMLA leave can be found on page 45 in the Personnel Policy.
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EXPLANATION
In order that the department be able to plan for and distribute your workload during the time
requested to be on leave days, reduced hour work schedule, and/or intermittent leave, it is
imperative that you explain in detail and give specific information, below, concerning the
requested work hours and/or time absent from work. (If additional space is needed, use back of
form)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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