Request For Leave of Absence

Request For Leave of Absence

Mt. Diablo Unified School District
Employee Name

First NameLast Name
Employee ID*
Bargaining Unit*
Job Title*
FTE
Work Site*
Reason For Leave*

Medical-SelfMedical-CaregiverPregnancy/MaternityParent Bonding (including: birth/adoption/Foster Care)Caring for military service memberLeave due to a qualifying to a qualifying exigency relating to military serviceGeneral Leave Without Pay
Leave will be:*

ContinuousIntermittent
If you are requesting intermittent leave please provide any known information regarding the intermittent or reduced leave schedule you are requesting You are also required to provide a medical note verifying this request*
During my leave, I can be reached at:
Address*
Phone Number*
Email Address*
example@example.com
By submitting this form, I understand that I am required to provide timely medical documentation for any medical leave, and notify Human Resources as well as continue to provide additional medical documentation should it be necessary should it be necessary to extend the leave.

Please refer to your respective Bargaining Unit agreement for more detailed information regarding your leave entitlements.
Employee Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: