Request for leave I would like to * Initiate Leave of Absence for a Staff Member Initiate Leave of Absence for Myself Request Consultation Requestor Email * Employee First Name * Employee Last Name * Employee Type * - Select -StaffStudent Employee Department * Phone Number * Preferred Contact Method * work email personal email phone number Reason for Leave of Absence * Other Military Care for injured/Ill Family Member Military Caregiver Leave Qualifying Exigency Leave Parental Bonding (Care for Newborn/Placed Child) Pregnancy/Disability Work-Incurred Injury/Illness Own Injury/Illness (not work related) Request start date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 Anticipated return date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027 Comments CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
