Embarcadero Leave of Absence Request

Today's Date*

Employee's First Name*

Employee's Last Name*

Job Title*

Address

City

State

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Zip Code

Employee Phone Number*

Employee Email Address

Preferred Method of Delivery*

Please select the preferred method of delivery of the paperwork.

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Is this a workplace injury?*

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Work Schedule*

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Work Week*

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How many hours does the employee work per week?*

Please list the total hours of the employee's typical work schedule in a single week.

Date Company Learned of Leave*

Consecutive or Intermittent Leave?*

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Leave Start Date*

Leave End Date

If unknown, leave blank.

Reason for Leave*

Select the reason for the employee's request for leave

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For Pregnancy/Bonding Only: Due Date

If the reason for leave is for bonding, please list the expected due date of the baby.

Age of child

If the leave reason is to care for a child, please list the child's age.

Relationship to Employee*

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Name of Qualifying Family Member

If the leave request is to care for a qualifying family member, please list their full name.

Does the employee have a completed medical certification or physician's note?*

If the employee has a completed medical certification or physician's note, please attach it below. For bonding/parental leave, select "Yes".

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Job Description/Medical Certification/Physician's Note

You may upload multiple documents. Job Description - Upload a copy of the employee's job description, if available. Medical Certification - If the employee has a medical certification or physician's note, please upload it here, as well.

Drag and drop files here or

Essential Job Functions

Employee's own serious health condition only: If the employee is requesting leave for their own serious health condition, please list the essential functions of the their position if a job description is not available. If a job description has been uploaded, please skip this field.

What state does the employee work in?*

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Does this employee work at more than one location?*

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If remote employee, what office/worksite location does employee report to?

Please list the city and state the employee is working from.

Name of Manager, Supervisor, or HR Manager who submitted this request*

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