Do not use this form if you are reporting an absence for same day or next day. Please call 800-249-6161 and follow the prompts.

LEAVE REQUEST

YOUR REQUEST FOR TIME OFF SHOULD BE SUBMITTED, SCHEDULED AND APPROVED BY MANAGEMENT IN ADVANCE. VACATION NORMALLY REQUIRES 2 WEEKS ADVANCE NOTICE.

To request time off, employee must fill out a Leave Request Form (LRF) and submit it to your Supervisor or Manager. They will either approve or deny based on any scheduling conflicts. If approved, they will then submit to Administration for final approval. Your request is not approved unless you receive a signed approval or e-mail approval from Administration. LRF’s are available for download here or at your local branch office. You may also complete the online form below.

DOWNLOAD LRF

If you would like to use vacation time for an unexcused absence, for example, an illness, you must fill out a leave request form requesting this on the day you return. No time will be paid without a leave request form. Requests not submitted upon return or after the end of a payroll will not be accepted. Not all positions provide for paid time off or vacation. This is determined by your position and assigned facility.

If you have any questions or concerns or need assistance completing this form, please contact Human Resources at 319-393-6162.

EMPLOYEE INFORMATION

Name *

Phone *

Email *

Branch *

Supervisor *

Today's Date * +

Correction to a previously submitted leave request form?

Yes

TYPE OF LEAVE / ABSENCE

Starting On * +

Return On * +

Time From

Time To

Total

Hours

Days

Paid or Unpaid Time Off * 🛈

Paid

Unpaid

PURPOSE

Do not complete a Leave Request Form for same day or next day call offs.

Employees must call 800-249-6161 and select Option 1.

Purpose * 🛈

Illness - Advanced Notification

Medical / Dental Examination for self

Care of Family Member (including medical/dental examination)

Bereavement

Vacation / Personal

Other - Must provide explanation below Other - Must provide explanation below

Remarks

FAMILY MEDICAL LEAVE

If leave will be used under the FMLA, please provide the following information:

I hereby invoke my entitlement to family and medical leave (FMLA):

(Initial)

Reason for FMLA

Birth/Adoption/Foster Care

Serious Health Condition of spouse, child or parent

Serious Health Condition of self

Family Member on Covered Active Duty

Care of Covered Service Member

ACKNOWLEDGEMENT

CERTIFICATION: I certify that the leave/absence requested above is for the purpose indicated. I understand that I must comply with MJS’s procedures for requesting leave/absence (and provide additional documentation, including medical certification, if required) and that falsification of information on this form may be grounds for discipline, up to and including, termination.

I understand that my leave request is not approved until I have received notification from my branch. I have not heard from someone within three (3) days, please contact your branch directly or call 319-393-6162. *

I understand the leave request policy.

Employee Name *

Date Signed * +

* 🛈

clear

PRIVACY ACT STATEMENT
Section 6311 of title 5, United States Code authorizes collection of this information. The primary use of this information is by management and the payroll department to approve and record your use of leave. Additional disclosures of the information may be: to the Department of Labor when processing claim for your compensation regarding a job connected injury or illness; to a Federal, state of local law enforcement agency when your agency becomes aware of a violation or possible violation of civil or criminal law; to a Federal Accounting Office when the information is required for evaluation of leave administration; or the General Service Administration in connection with its responsibilities for records management.