Request for leave You must have JavaScript enabled to use this form. I would like to * Initiate Leave of Absence for Myself Initiate Leave of Absence for a Staff Member 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 * Care for injured/Ill Family Member Pregnancy/Disability Qualifying Exigency Leave Work-Incurred Injury/Illness Other Military Parental Bonding (Care for Newborn/Placed Child) Military Caregiver Leave Own Injury/Illness (not work related) 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.
