Leave of Absence Request Form – Enhance Therapies

Request for Leave of Absence

Are you requesting a leave for yourself or as a supervisor on behalf of an employee?

First Name

Last Name

Phone Number

Email Address

Discipline

Business Unit

State of Employment

Facility Name

Leave Reason

Is This Leave Request Related to a Work Injury?

Yes

Have you Notified Your Supervisor About Your Leave?

Yes

Expected Last Day of Work

If dates are estimates, please explain why in the "comments" section below.

Date disability/leave expected to begin

Expected Return Date

If dates are estimates, please explain why in the "comments" section below.

Are These Dates Flexible

Yes

Please explain your reason for leave in more detail in the comment box below or any additional information related to your request.

File Upload

Maximum file size: 516MB

If you are human, leave this field blank.