2. Please complete this form to the best of your knowledge. Once submitted, your HR Representative will contact you within 1 business day.
4. Employee Name:*
5. Department*
   -- Select One --AS-FacilitiesAS-Human ResourcesAS-ITAssessorAuditorCooperative ExtensionCouncilDistrict CourtDistrict Court ProbationExecutiveHealthJuvenile CourtJuvenile DetentionParksPDSProsecuting AttorneyPublic DefenderPublic WorksSheriffSuperior CourtTreasurer
7. I am requesting leave due to the following reason:*

   1. My own serious health condition which makes me unable to perform the functions of my job.
   2. A serious health condition affecting my spouse, child, or parent for which I need to provide care.
   3. Birth of a child and/or to care for my newborn child.
   4. Placement of my child through adoption or foster care.
   5. Covered military service member with a serious injury or illness who is my spouse, child, parent, or next of kin.
   6. Qualifying exigency arising from my spouse, child, or parents called for military deployment in a foreign country.
   7. Other
9. Please provide more information on your need for leave:
11. Anticipated date leave is to begin:*
    Anticipated date leave is to begin:
12. Date leave is to end (if known) :
    Date leave is to end (if known) :
14. My leave will be taken:*

    1. Consecutively
    2. Intermittently
16. How would you like to be contacted?*
    -- Select One --By emailBy phoneBy mail to my homeBy interoffice mailIn person
18. Email:
20. Phone number:
22. Mailing address:
24. Please provide additional information here, if needed:
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

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