Law Enforcement Stress Leave of Absence Form
Submit your request for a leave of absence due to stress. Please provide all required details to help us process your request efficiently.
Full Name
*
First Name
Last Name
Badge or Employee Number
*
Department/Unit
*
Supervisor's Name
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Dates Requested for Leave (Start and End Dates)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Leave Request
*
Which of the following stress factors have contributed to your leave request?
*
Workload
Critical Incident Exposure
Interpersonal Conflict
Organizational Stress
Personal/Family Issues
Other
Have you previously taken any steps to address work-related stress? (Check all that apply)
*
Spoke with supervisor
Sought counseling/support
Used employee assistance program
Took time off (vacation, sick leave, etc.)
No prior steps taken
Other
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
Submit Request
Submit Request
Should be Empty: