Medical Leave

A full time employee who is not eligible for FMLA may request medical leave. This is an unpaid leave of absence that can be taken a minimum of 5 consecutive days, up to a maximum of 4 weeks for absences due to:

An employee’s own illness or disability

An employee will not accrue PTO during this leave of absence.

Employee's First Name

Last Name

Location/Program

Location/Program Address

Location/Program City State Zip

If your location is not listed above, please specify

Requested length of Leave of Absence

From

Please provide a short description for this Leave of Absence request

Please upload a copy of your doctor's note

IMPORTANT - READ BEFORE SIGNING

I have read and understand the guidelines of Medical Leave as outlined in the employee handbook. I also understand that this Leave of Absence is unpaid, PTO does not accrue and I am responsible for paying my benefits premiums to EDSI during this leave.

Date

Full Name

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Medical Leave

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