Leave of Absence (LOA) Request Form
An employee must have been employed for one (1) year to request a leave. A written request for a personal leave must be submitted to the Human Resource Director at least sixty (60) days before the anticipated start of the leave.

The Family and Medical Leave Act (FMLA) entitles eligible individuals to take unpaid, job-protected leave for specified family and medical reasons. When an employee requests FMLA leave due to his or her own serious health condition or a covered family member's serious health condition, Ability Matters requires certification in support of the leave from a health care provider. Approval/Disapproval will be determined in accordance with federal regulation.

The employee must meet the following work requirements to be FMLA eligible: Must have worked a minimum of 12 months for Ability Matters, and have worked at least 1250 hours the immediately preceding 12 months.

Upon completion of the personal leave of absence (NON-FMLA), the Agency will attempt to return employees to their original job or a similar position, subject to prevailing business considerations. Reinstatement, however, is not guaranteed.
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Date Form Completed:  *
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Employee First Name: *
Employee Last Name: *
Name of Your Department Director *
Type Of Leave  *
Beginning date of leave: *
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Date of estimated return: *
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Explanation for Request: *
If traveling outside of the US, what is your destination?
Note Section: 
Notified of Status:  *
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