Leave forms

Family and Medical Leave Request

An employee requesting family-medical leave must submit the Protected Family and Medical Leave Request Form (pdf version) or (fill-in Word version) to his/her leave-granting authority.

Medical Certification Forms for Family and Medical Leaves of Absence

To take a leave of absence for a family or medical leave condition, an employee must ask an approved health care provider to certify the condition by completing and signing one of the following medical certification forms:

• Certification of Health Care Provider for Employee's Serious Health Condition – for a leave to care for your own serious health condition.
• Certification of Health Care Provider for Family Member's Serious Health Condition – for a leave to care for the serious health condition of your qualified family member.
• Certification of Serious Injury or Illness of Covered Servicemember for Military Family Leave – for a leave to care for the serious injury or illness of your qualified military service member.
• Certification of Qualifying Exigency for Military Family Leave – for an exigency leave related to your qualified family member’s military deployment.

Family and Medical Leave Request Response

An employee's leave-granting authority uses the Protected Family and Medical Leave Response Form (pdf version) or (fill-in Word version) to respond to a family-medical leave request.

Leave of Absence Without Pay Request

An employee must submit the Leave of Absence Without Pay Request Form (pdf version) to request leave without pay.

Activities Prescription Form

An employee who has medical restrictions and might need accommodation when returning to work may be asked to submit the Activities Prescription Form. If you need help completing this form, contact your safety and claims representative. Generally, this form is used in conjunction with workers' compensation claims.

Leave Donation Form

An employee uses the Leave Donation Form (pdf version) or (fill-in Word version) to donate leave accruals to another employee.

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If you need help with the Leave Donation Form, the Donated Leave Chart provides comprehensive information regarding donated leave including union contract information, minimum and maximum hours and conversion data. If you have questions about the donated leave chart, please contact your human resource or service delivery manager.

Uniformed Services Leave Form

An employee who is going on leave for military training or active service must submit the Uniformed Services Leave Form (pdf version) or (fill-in Word version) to his/her department military leave coordinator.