Request for leave 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 * Military Own Injury/Illness (not work related) Military Caregiver Leave Care for injured/Ill Family Member Pregnancy/Disability Other Parental Bonding (Care for Newborn/Placed Child) Qualifying Exigency Leave Work-Incurred Injury/Illness 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.
