REQUEST FOR INTERMITTENT FMLA, PFL, PPL, & LOD TIME OFF ONLY

Date of Request

Employer:

Time off Duty for:

Name:

Title:

Select One:

FMLAPFLPPLLOD

FMLA (Family Medical Leave Act) - Accruals will be used if available

PFL (Paid Family Leave) - Can only be taken in full days

PPL (Paid Prenatal Leave)

LOD (Living Organ Donor)

To Begin (Date):

Hour:

To End (Date):

Hour:

TYPE OF TIME OFF REQUESTED

(Indicate number of hours by the appropriate box in one quarter or whole units of hour for FMLA only)

PFL - *Do not wish to use my accruals*

Annual Leave Total # of Hours

Sick Leave Total # of Hours

Personal Leave Total # of Hours

Supplemental Time Total # of Hours

Holiday Leave Total # of Hours

Name of Holiday:

Annual Leave Total # of Hours

Sick Leave Total # of Hours

Personal Leave Total # of Hours

Holiday Leave Total # of Hours

Name of Holiday:

Annual Leave Total # of Hours

Personal Leave Total # of Hours

PTO Total # of Hours

LT Sick Leave Total # of Hours

Sick - NYSNA Total # of Hours

Sick Leave Total # of Hours

Holiday Leave Total # of Hours

Name of Holiday:

Holiday Leave Total # of Hours

Name of Holiday:

LTI Total # of Hours

PTO Total # of Hours

Sick Leave Total # of Hours

Personal Leave Total # of Hours

Vacation Leave Total # of Hours

Do you report to Nursing or Nursing Staff?

YesNo

Please select:

EMPLOYEE SIGNATURE

Submission of this form will serve as notification to Leave Management and my supervisor that I will be utilizing Intermittent FML and/or PFL.

Signature of Requesting Employee:

MANAGER CONTACT INFORMATION

Manager Name:

Manager Email: