Leave Of Absence
ADMIN ONLY
Business Hours ID
Record Type -
Calculated
Admin:id
Admin:timestamp
Admin:pocid
Admin:pocemail
Preload Successful
Yes
Submitter User ID
- Dynamic
Submitter Contact ID
- Dynamic
Submitter Contact Name
- VAR
Submitter Contact Email
- VAR
Lookup Email
-
Calculated
Submitter Contact Phone
POC Name
POC Phone
Is Employee Health -
VAR
Yes
No
Category -
VAR
Role
Case Origin
Attachment Negation Key
Supervisor Email Hidden
- Dynamic
Supervisor ID Hidden
- Dynamic
Employee's Name Hidden
- Dynamic
Employee's Email Hidden
- Dynamic
Employee's ID Hidden
- Dynamic
Submitter Information
Your Name
Your Email
Your Name
Your Email
Phone number
Affected Employee Information
Employee Type
Please select...
Academic
Staff
Student
Submitting request on behalf of?
Self
Another
Employee's Name / Email
Employee Name
Employee UC Davis Email
To determine an employee's email address, please visit
UC Davis Online Directory
.
Preferred Alternate Email Address
If no alternate information is provided, we will use the email and/or phone available in the UC Davis directory.
Preferred Alternate Phone Number
Are you employed at?
Please select...
Health
Campus
Don't Know
Academic Health Employees please contact
Academic Personnel
.
Employee's Supervisor's Name / Work. Email
Employee's
Supervisor Name
Employee 's
Supervisor Work Email
Your supervisor will be notified that you are requesting leave. If you have a question please submit an Ask-A-Question.
Employee Bargaining Unit
Please select...
99s - Non Represented
BR
BX
CX
DX
EX
F3
HX
K3
NX
PA
RX
SX
TX
Patient Care Technical
EX
(AFSCME), Service Unit
SX
(AFSCME), Clerical & Allied Services
CX
(Teamsters), Health Care Professionals
HX
(UPTE)
Research Support Professionals
RX
(UPTE), Technical Unit
TX
(UPTE), Nurses
NX
(CNA),
Unrepresented Employees
99
Employee Bargaining Unit
Please select...
99s - Non Represented
BR
BX
IX
LX
PX
RA
Patient Care Technical
EX
(AFSCME), Service Unit
SX
(AFSCME), Clerical & Allied Services
CX
(Teamsters), Health Care Professionals
HX
(UPTE)
Research Support Professionals
RX
(UPTE), Technical Unit
TX
(UPTE), Nurses
NX
(CNA),
Unrepresented Employees
99
Leave Details
Is this for an existing case?
Yes
No
Case Number #
e.g. 00654321
Start Date
Expected Return Date
If known
Leave Type
Please select...
Block - Continuous dates of absence
Intermittent - Periodic leave of absence
Reduced - Working reduced hours per day
Academic Leave Type
Please select...
Administrative Leave
Child Bearing Leaves
Employee's Own Serious Health Condition
Expired Work Authorization
Family Member with a Serious Health Condition
Furlough
Military FML Caregiver Leave
Military FML Qualifying Exigency Leave
Military Leave
Parental Bonding Leave
Personal Leave
Pregnancy Leave
Professional Development
Reproductive Loss Leave
Sabbatical
Union Business
Victims of Domestic Violence / Sexual Assault / Serious/Violent Felonies Leave
Other
Reason for Leave
Please select...
Administrative Leave
Employee's Own Serious Health Condition
Family Member with a Serious Health Condition
Furlough
Military FML Caregiver Leave
Military FML Qualifying Exigency Leave
Military Leave
Parental Bonding Leave
Personal Leave
Pregnancy Leave
Reproductive Loss Leave
Union Business
Victims of Domestic Violence / Sexual Assault / Serious/Violent Felonies Leave
Other
Work Related?
Yes
How many
sabbatical credits
are being used ?
# of Sabbatical Credits used
Pay Request Type
Please select...
Vacation
Sick
Pay Family Care Bonding(PFCB)
Paid Time Off Sick - PTO(S)
Paid Time Off Personal - PTO(P)
Paid Time Off (PTO) - Extended Sick Time
Leave Without Pay
Holiday Earned
Holiday Banked
Compensatory Time (CTO)
Catastrophic Leave
Other
Click here
for more info in regard to Pay Request Type
Pay Type / Frequency
Please select...
Biweekly
Monthly
Pay Option
Please select...
With Pay
Without Pay
Salary Option
Please select...
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
Other
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
Contact Information