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Additional information about employee leave of absence rights (including FMLA) and responsibilities will be provided to you in writing within five business days after receipt of this notice (unless already provided). Determination of eligibility for leave under FMLA and other leave of absence laws and/or additional documentation or clarification of documentation, may be required prior to making a final determination to approve any leave request. Please contact People Operations with any questions. Please return this form with documentation supporting your request for a leave of absence. (physician’s statement, military orders, or additional information)

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Phone Access

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Open to Religious Affiliated Organization

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Employee Name

Requested Leave Start Date

Estimated Return Date

Employee Type

The Reason for this Leave Request

The reason for this leave request is (select the most appropriate box):

Birth of a son or daughter and to care for the newborn child. Placement with the employee of a son or daughter for adoption or foster care. To care for the employee's spouse, son, daughter or parent with a serious health condition. A serious health condition that makes the employee unable to perform the functions of the employee's job. COVID related illness or caregiving responsibilities A qualifying exigency arising out of the fact that the employee's spouse, son, daughter or parent is a military member on covered active duty (or has been notified of an impending call or order to covered active duty status). To care for a covered servicemember with a serious injury or illness if the employee is the spouse, son, daughter, parent or next of kin of the covered service member. To care for the employee’s child when the employee is unable to work (or telework) due to the closing of the child’s school, place of care, or unavailability of the regular childcare provider due to a public health emergency with respect to COVID-19. Other: Type In Message Box Below

Time Off Work Expected To Be

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