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CITY OF PUYALLUP LEAVE REQUEST/REPORT Date: Employee Name: Beginning Date: Time Ending Date: Time Total Hours Leave: Type of Leave: Vacation Annual (Floating Holiday) Sick Leave (Self: Non-FMLA) Explanation: Sick Leave (Self: FMLA) Explanation: Sick Leave (Family care: Non-FMLA) Explanation: Relationship: Sick Leave (Family care: FMLA) Explanation: Relationship: Sick Leave (Work-related L & I) Explanation: Other Leave (Jury Duty, Bereavement, Military Leave, etc.) Explanation: Leave of Absence Without Pay (PAF required) Explanation: Comp-time Employee signature Date (Supervisor signature for oral requests) Leave Approved Leave Denied Supervisor: Contact Human Resources as soon as possible regarding any requests for time off (including oral requests) if the reason may be an FMLA-qualifying event. See the reverse side for further information regarding FMLA leave. Supervisor Signature Date Original to be retained by the immediate supervisor with a copy to the employee. COVID-19 Vaccine SIGN SIGN ---PAGE BREAK--- The Family and Medical Leave Act (FMLA) The City of Puyallup grants up to 12 weeks of family and medical leave during any 12-month period to eligible employees, in accordance with the Family and Medical Leave Act of 1993 (FMLA). The leave may be paid or unpaid, depending on the circumstances and as specified in the collective bargaining agreement and/or City policy. In order to qualify as FMLA leave, you must be taking leave for one of the reasons listed below: the birth of a child in order to care for that child; the placement of a child for adoption or foster care; to care for a spouse, child, or parent with a serious health condition; or the serious health condition of the employee that makes the employee unable to perform the functions of his/her position. Please Note: Having time off designated as FMLA leave still allows you to use accrued paid leave, such as sick leave or vacation. Definitions under the FMLA: “Serious health condition” means a health condition which involves: Inpatient treatment an overnight stay); A period of incapacity of more than three consecutive calendar days and, in addition, continuing treatment by a health care provider; A period of incapacity due to pregnancy or prenatal care; A chronic, serious health condition asthma); A permanent or long-term period of incapacity because of a condition for which treatment may not be effective Alzheimer’s); Multiple treatments for restorative surgery; or Multiple treatments for a condition which would likely result in a period of incapacity of more than three consecutive calendar days if not treated cancer). “Child” means a biological, adopted, or foster child, a stepchild, a legal ward, or a child of a person standing in loco parentis who is: under eighteen years of age; or eighteen years of age or older and incapable of self-care because of a mental or physical disability. “Parent” means a biological parent of an employee or an individual who stood in loco parentis to an employee when the employee was a child. Requesting Leave: Except where leave is not foreseeable, all employees requesting leave for FMLA-qualifying events must submit the request in writing to their immediate supervisor, (with a copy to Human Resources) 30 days in advance. If it is not possible to give 30 days notice, the employee must give as much notice as is practicable. Supervisors must immediately notify Human Resources of any request for leave which may be an FMLA qualifying event. If you are not sure whether or not the absence is for an FMLA-qualifying event, please contact the Human Resources Department at 841-5460. Please refer to the City’s FMLA Policy and Procedure 2.7.6 (or FMLA operational guidelines if applicable to your department) or contact the Human Resources Department for more information.