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UC Davis Staff Leave Form

This document is a staff leave request form for an employee of the University of California, Davis. The employee provides their personal information and selects the reason for their leave, such as their own health condition, care of a family member, or work injury. They then request the start and anticipated return dates and describe if their schedule will be intermittent or reduced. Finally, the employee estimates the type and hours of paid or unpaid leave they wish to use. The form is then sent to the employee's department for approval and designation of what portions of the leave qualify as family or medical leave.

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Dave Brijesh
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54 views1 page

UC Davis Staff Leave Form

This document is a staff leave request form for an employee of the University of California, Davis. The employee provides their personal information and selects the reason for their leave, such as their own health condition, care of a family member, or work injury. They then request the start and anticipated return dates and describe if their schedule will be intermittent or reduced. Finally, the employee estimates the type and hours of paid or unpaid leave they wish to use. The form is then sent to the employee's department for approval and designation of what portions of the leave qualify as family or medical leave.

Uploaded by

Dave Brijesh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY OF CALIFORNIA, DAVIS

Staff Leave Request


Employee: Please complete the top section

Employee: Employee ID: Campus Phone:

Home Mailing Address & Phone:

Department: Title:

Please check reason for leave of absence:

Own serious health condition (not work related) .................
Care for newborn/placed child ...............................................
Pregnancy disability ..................................................................
Care for parent/spouse/child w/serious health condition
Work-incurred injury ................................................................
Other ...........................................................................................

Requested Start Date: Anticipated Return to Work Date:

Intermittent or reduced work schedule (describe):

A leave of absence may consist of leave without pay and/or paid leave (vacation, sick leave, compensatory time off).
Paid leave may be used in accordance with applicable policy/contracts.

I wish to use leave as estimated below:

Type Hours From Through
Vacation ____________ ____________ ____________
Sick Leave ____________ ____________ ____________
Comp Time Off ____________ ____________ ____________
Leave w/o Pay ____________ ____________ ____________

Employee signature & date:

Designation of Leave
Department: Please complete the bottom section

Initial application? Revision? (describe)

Your leave is provisionally approved pending medical verification.

Your leave is approved.

Your leave is denied for the following reason(s):

From Through
____________ ____________ qualifies as Family & Medical Leave
____________ ____________ qualifies as Pregnancy Disability Leave
If both FML and PDL apply, the begin dates will be the same.

Confirmation of status during leave:

Type Hours From Through
Vacation ____________ ____________ ____________
Sick Leave ____________ ____________ ____________
Comp Time Off ____________ ____________ ____________
Leave w/o Pay ____________ ____________ ____________
Supplemental FML ____________ ____________ ____________
Personal Leave ____________ ____________ ____________

Supervisor signature & date:

Supervisor name (please print): Phone:

Copy to: Employee, Department, Benefits
Retention: 3 Years
Print Form

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