Company: [Company]

This form is used to notify [Company] of a request for a medical leave of absence and/or workplace accommodation. It assists Human Resources in evaluating the request, engaging in the interactive process where applicable, and supporting operational planning.

Completion of this form does not constitute approval of a leave of absence, workplace accommodation, modified work schedule, or return to work plan.

EMPLOYEE INFORMATION

Employee Name:______

Job Title:______

Department:______

Direct Manager:______

Primary Contact Email:______

Phone Number During Leave:______

REQUEST TYPE

______

REQUEST DETAILS

Anticipated Start Date:______

Expected Return Date:______

This request relates to:______

Requested leave, accommodation, schedule modification or restriction:

______

Requested schedule, frequency and duration for intermittent or reduced schedule:

______

Current Work Status:______

Previously discussed with HR:______

Date discussed with HR:______

SUPPORTING DOCUMENTATION

• Supporting medical documentation must be provided when requested by HR and where permitted by applicable law.
• Medical documentation should identify functional work restrictions, anticipated duration, and any recommended leave, schedule modification, or workplace accommodation relevant to the request.
• The Company may request additional, updated, or clarified documentation when necessary to evaluate or administer the request.
• A healthcare provider's recommendation or certification does not, by itself, approve or authorize a leave of absence, workplace accommodation, modified schedule, extension of leave, or return to work restriction.

NOTICE TO COMPANY

Date Employee first became aware leave or accommodation may be needed: ______

Was the need foreseeable:______

Date Employee notified Manager:______

Date Employee notified HR:______

Method of notification:______

If the need was foreseeable and less than 30 days advance notice was provided:

______

WORK TRANSITION PLANNING

Employee is expected to coordinate with their Manager to transition active work, projects, client responsibilities, documentation, and other operational needs before approved leave begins.

EMPLOYEE ACKNOWLEDGEMENT

The Employee acknowledges that:

• Submission of this form is a request for review only.
• No leave of absence, modified work schedule, workplace accommodation, intermittent or reduced schedule, extension of leave, or return to work restriction is approved unless confirmed in writing by Human Resources or otherwise required by applicable law.
• The Employee must continue to comply with Company attendance, scheduling, and work expectations until an applicable legally protected leave begins or Human Resources provides written approval of a change.
• A healthcare provider's recommendation, certification, or other medical documentation does not independently authorize the Employee to stop working, modify their work schedule, extend an absence, or work under restrictions.
• Requests submitted without sufficient advance notice may impact the Company's ability to evaluate and administer the request, except where advance notice is not reasonably practicable or otherwise required by applicable law.
• Employees are expected to provide notice as soon as practicable for foreseeable medical leave or accommodation requests.
• The Company may engage in an interactive process and may require additional, updated, or clarified documentation before making a determination.
• PTO, discretionary time off, sick leave, floating holidays, or other Company provided paid time off may not be used to extend, bridge, or supplement time immediately before or after an approved leave period, except where required by applicable law or expressly approved in writing by HR and Executive Leadership.
• Employees are expected to return to work on their approved return date. Failure to return to work for two consecutive scheduled workdays following the approved return date, without a legally protected absence or written Company approved extension, will be handled under the Company's Job Abandonment and Voluntary Resignation Policy and may be treated as a voluntary resignation.

Employee Signature:____________________ Date: ____________