Short Term Family Leave Request Form

IMPORTANT: Please carefully read all of the text below this sentence PRIOR TO filling out the form.

Employees are entitled to short term leave of up to 4 hours in any 30-day period (but not more than 24 hours in any 12 month period) of unpaid leave. This short term family leave is available for employees to participate in preschool or school activities directly related to the academic advancement of the worker’s child, stepchild, foster child, or ward who lives with the worker; to attend or to accompany the worker’s child, stepchild, foster child, or ward who lives with the worker or the worker’s parent, spouse, or parent in law to routine medical or dental appointments; to accompany the worker’s parent, spouse, or parent in law to other appointments for professional services related to their care and wellbeing; to respond to a medical emergency involving the employee’s child, stepchild, foster child or ward who lives with the worker or the employee’s parent, spouse or parent in law.

The employee is required to give reasonable written notice of intent to take family or medical leave, including the anticipated dates that the leave will start and end. For short term family leave, the employee must give notice as early as possible, at least seven days before the leave is needed to be taken unless waiting seven days could have a significant adverse impact on the employee’s family member.

Short Term Family Leave Request Form

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Date & Time Requesting Off*

Explanation for Time Off:*

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