Family Leave Job Protection Request Form
Use this form to request job-protected family leave. Please complete all fields accurately.
Full Name
*
First Name
Last Name
Employee ID
*
Department
*
Please Select
Human Resources
Finance
Operations
Sales
Marketing
IT
Other
Job Title
*
Work Email
*
example@example.com
Supervisor/Manager Name
*
Type of Family Leave Requested
*
Please Select
Parental Leave
Care for Family Member
Military Family Leave
Other
Start Date of Leave
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date of Leave
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brief Reason for Leave (do not include sensitive or medical details)
*
Please describe any job protection or work coverage arrangements requested
Submit Request
Should be Empty: