Transportation Worker Injury Recovery Leave of Absence Form
Submit your request for leave due to injury recovery. Please complete all sections for proper processing.
Full Name
*
First Name
Last Name
Employee ID Number
*
Job Title / Position
*
Department / Work Location
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Injury
*
-
Month
-
Day
Year
Date
Please describe the nature of your injury
*
Requested Leave Start Date
*
-
Month
-
Day
Year
Date
Requested Leave End Date (if known)
-
Month
-
Day
Year
Date
Medical Provider Name / Facility
Upload medical documentation supporting your leave request
*
Upload a File
Drag and drop files here
Choose a file
Cancel
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Supervisor or Manager Name
*
Signature
*
Submit Leave Request
Submit Leave Request
Should be Empty: