Leave of Absence Request

Request a Leave of Absence from AltaStaff

1. Select an option:

Initial Leave Request

Extension of Leave Request

*Note: Extensions require approval and timely submission of appropriate documentation
to support the request

2. Contact information:

First name

Last name

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

*Note: Medical Leave (Medical Leave requests may require a signed Medical Certification from an approved Medical Practitioner)

3. Choose a Reason For Leave:

Other:

Date Leave Starts:

Date Leave Ends:

Return to Work Date:

Note: A return from leave due, to a medical issue, may require medical clearance before returning to work

4. Insurance Options

I understand insurance with AltaStaff for myself and my dependent(s), if applicable, during my Leave of Absence(LOA) will continue. By checking this box I agree to continue payment of my monthly contributions, 30 days before the first of each month coverage is offered. Note Regarding New Dependents: If you acquire a new dependent while on leave, you must enroll that dependent in Human Resources

Regarding New Dependents: I understand that If I acquire a new dependent while on leave, you must enroll that dependent in Human Resources within 30 days of the date of birth, adoption or marriage.

Note: Where leave is foreseeable, an employee should provide notice of leave to the employer as possible. After the first workday of paid sick time, an employer may require employees to follow reasonable notice procedures in order to continue receiving paid sick time.

Return to Work: Even if an employee has not used all the paid sick time, the employee must return to work at the employee’s next scheduled work shift after the need for leave ends.

No Discrimination or Retaliation: No discrimination or retaliation is permitted against employees for taking paid sick leave under the new law or for reporting complaints, testifying or instituting proceedings related to the law.

Please review AltaStaff Employee Manual for additional information regarding FMLA and Leave of Absence policies.

5. Your Signature

Date Signed:

Request a Leave of Absence from AltaStaff

*Note: Extensions require approval and timely submission of appropriate documentation to support the request 2. Contact information:

*Note: Medical Leave (Medical Leave requests may require a signed Medical Certification from an approved Medical Practitioner)

Note: A return from leave due, to a medical issue, may require medical clearance before returning to work

*Note: Extensions require approval and timely submission of appropriate documentation
to support the request

2. Contact information: