UP Leave Request Form

1. Employee Name

2. UP ID Number

3. Faculty or Staff?

4. Best Personal Email Address

5. Best Personal Phone Number

6. Best Personal Mailing Address

7. Name & Phone Number of Emergency Contact

8, When is the anticipated start date of your leave?

9. When is your anticipated full return-to-work date?

If you are not certain of what this date is, please write in a date to the best of your knowledge. In the "More Info" section below, you can note that you are uncertain of the return-to-work date.

10.a. Is your leave continuous or discontinuous?

Discontinuous means that you may do some work (at work or at home) during the period of time when you need leave.

10.b. If your leave is discontinuous, please explain the days or weeks you will be taking as leave.

{name}

10.c. If your leave part-time, please explain how many hours per day or days per week you can work.

Part-time means that your health care practitioner is recommending that you work part days or part weeks.

{name}

11. Reason for Leave

More information about different reasons for leave protected by federal and/or Oregon law are located at: www.bitly.com/boli-ofla www.bitly.com/boli-ofla-handout https://www.dol.gov/agencies/whd/fmla https://paidleave.oregon.gov/employees/overview.html The definition of a "serious health condition" is at: https://webapps.dol.gov/elaws/whd/fmla/10c2.aspx

12. Metlife Paid Family Medical Leave

Please answer if you applied or planning to apply PFML Oregon. (Bereavement leave is not applicable for this benefit) If your answer is Yes->answer question 13 No->skip question 13 Information about Paid Leave Oregon: https://paidleave.oregon.gov/employees/overview.html

13. Metlife Paid Family Medical Leave - Top up

If the Metlife Paid Family Medical Leave pay is less than 100% of the employee’s regular wages, the employee may elect to “top up” their pay approximately up to 100% of their regular University wages through the application of sick accrual hours and then vacation accrual hours. Do you wish to top up?

14. Metlife Paid Family Medical Leave - Waiting Period

Do you want to apply available sick/vacation while you are on waiting period? * If you decided to use your sick/vacation hours to cover your wage for the waiting period, there will be a possibility that you will end up receiving more than 100% of your wage. The University will not collect the money we pay. Please work on the tax filing when you claim the wage.

15. If the reason for leave is birth, adoption, or foster care, when is the anticipated birth or placement date?

16. Is your leave related to a work injury?

17. Have you alerted your supervisor for duty coverage purposes?

The only information that an employee has to communicate to a supervisor are the anticipated start and end dates, whether leave will be continuous or discontinuous, and whether HR has been contacted. Employees do not have to explain the reason for leave to a supervisor.

Yes
No

18. More Info?

If you think it would be helpful for Human Resources to know anything else related to your leave request, please write it below.

{name}

19. Attachments

Please attach documents related to your leave request: such as 1)Health Care Provider (Doctor's) note for yourself of Family 2)Birth Certificate 3)Note from Government etc. Employees on a work injury leave should submit all documentation received from a health care practitioner here or at www.bitly.com/up-leave-updates.

Attach file

Drop files here

Your Signature

Please enter your name below to indicate that you have filled out this leave request form honestly and to the best of your ability and knowledge.

Signature Date

Please enter the date when you signed this form.

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