Medical Leave of Absence Request (Nurse)
Submit your medical leave request as a hospital nurse. Please complete all required fields for HR processing.
Nurse's Full Name
*
First Name
Last Name
Employee ID Number
*
Department/Unit
*
Please Select
Emergency Room
Intensive Care Unit (ICU)
Pediatrics
Surgery
Oncology
Maternity
Other
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Leave Start Date
*
-
Month
-
Day
Year
Date
Leave End Date (Expected Return)
*
-
Month
-
Day
Year
Date
Type of Leave Requested
*
Medical (Self)
Family Medical
Personal Injury
Other
Reason for Leave (please provide brief details)
*
Upload Physician's Note or Supporting Medical Documentation (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
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Supervisor's Name
*
Emergency Contact Name and Phone Number
*
Submit Leave Request
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