Leaves
ADMIN ONLY
Preload Successful
Yes
Record Type
Submitter User ID
Submitter Contact ID
Submitter Contact Name
Submitter Contact Email
Lookup Email
Submitter Contact Phone
Admin:pocid
POC Name
Admin:pocemail
POC Phone
Is Employee Health
Yes
No
Category
Role
Case Origin
Business Hours ID
Attachment Negation Key
Supervisor Email Hidden
Supervisor(C) Hidden
Employee's Name Hidden
Employee's Email Hidden
Employee's (C) Hidden
Submitter Information
Your Name
Your Email
Your Name
Your Email
Phone number
Affected Employee Information
Employee's Name / Email
Employee Name
Employee UC Davis Email
Is there alternative contact information?
Is there a preferred alternate contact phone number or email address? If no alternate information is provided, we will use the email and/or phone available in the UC Davis directory.
To determine an employee's email address, please visit
http://directory.ucdavis.edu
Phone number
Employee Type
Academic
Staff
Student
Leave Details
Is this for an existing case?
Yes
No
Case Number #
e.g. 00654321
Supervisor's
UC Davis
Name / Email
Supervisor Employee Name
Supervisor UC Davis Email
Start Date
Return Date
If known
Leave type
Block (Continuous dates of absence)
Intermittent (Periodic leave of absence)
Reduced (Working reduced hours per day)
Academic Leave Type
Administrative Leave
Employee's Own Serious Health Condition
Family and Medical Leave - Qualifying Exigency Leave
Family Member with a Serious Health Condition
Furlough
Military Caregiver Leave
Military Leave
Military Spouse/Domestic Partner Leave
Parental Bonding Leave
Personal Leave
Pregnancy Disability Leave
Sabbatical
Union Business
Victims of Domestic Violence or Sexual Assault Leave
Victims of Serious or Violent Felonies Leave
Other
Staff/Student Leave Type
Administrative Leave
Employee's Own Serious Health Condition
Family and Medical Leave - Qualifying Exigency Leave
Family Member with a Serious Health Condition
Furlough
Military Caregiver Leave
Military Leave
Military Spouse/Domestic Partner Leave
Parental Bonding Leave
Personal Leave
Pregnancy Disability Leave
Union Business
Victims of Domestic Violence or Sexual Assault Leave
Victims of Serious or Violent Felonies Leave
Other
Work Related?
Yes
How many
sabbatical credits
are being used ?
# of Sabbatical Credits used
Salary Type
Hourly
Monthly
Pay Option
With Pay
Without Pay
Salary Option
Regular - Full Salary
Regular - Partial Salary
In Residence - Full Salary
In Residence - Partial Salary
Partial Salary Percentage
Family Member
Please select...
Spouse
Child
Domestic Partner
Parent due to his/her own serious health condition
Family Member
Please select...
Spouse
Child
Domestic Partner
Parent who is a covered military member of active duty or call to active duty
Family Member
Please select...
Spouse
Child
Domestic Partner
Next of kin of a covered servicemember with a serious injury or illness
Other Description
Is there anything else you'd like us to know about this request?
Client Reference Tag
Optional: for your reference only
Attachments
Attachment
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Contact Information