Leave Request Form

Name*
First Last
Email*
FMLA-Qualifying Event
- No
- Yes
For partial days, or a combination of leave types, please provide details in the additional comments below.
Type of Leave*
- Vacation
- Sick
- Other
Leave Begin Date*
MM slash DD slash YYYY
Begin Time*

: Hours

Minutes

AM/PM
Return-to-Work Date*
MM slash DD slash YYYY
Return-to-Work Time

: Hours

Minutes

AM/PM
Total Hours Requested*

Please round to the closest .25, .50, .75, or whole hour increment as appropriate.
Additional Comments