Request for leave You must have JavaScript enabled to use this form. I would like to * Request Consultation Initiate Leave of Absence for a Staff Member Initiate Leave of Absence for Myself 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 * Parental Bonding (Care for Newborn/Placed Child) Other Work-Incurred Injury/Illness Military Caregiver Leave Pregnancy/Disability Care for injured/Ill Family Member Own Injury/Illness (not work related) Qualifying Exigency Leave Military Family Member who is ill/injured * Spouse Domestic Partner Designated Person Child Parent Parent-In-Law Grandparent Grandchild Sibling Request start date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Anticipated return date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Comments Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
