State of Colorado Leave/Absence Request and Authorization
Any medical information is confidential and must be kept in separate files with limited access.
N
ame Employee ID #.
Department & Division
Work #
I understand that leave must be requested and approved in advance, where foreseeable. I understand that I must provide sufficient
information so the proper type of leave can be determined. I understand that I am responsible for keeping my supervisor informed of
any change in this request. If a medical condition is highly sensitive, directly contact your Family/Medical Leave coordinator immediately
.
I request approval for
total hours as listed below. Is the absence due to a work-related illness or injury? No Yes
Record dates, times, and number of hours in the blanks before each applicable reason. (More information may be required.)
Actual Dates & Times
From To # Hrs.
Vacation (not related to care/treatment of a medical condition or
bonding with a new child)
Medical. If not self, relationship
Routine eye, medical, dental exam.
Common illness/injury (no prescribed treatment, e.g., cold, flu)
Other Medical (inpatient or continuing treatment, e.g., surgery,
childbirth). Explain reason.
Other (Explain reason & relationship, e.g., bonding, funeral, jury,
adoption).
Check Here If Form
Employee Signature Date Amended □
To Be Completed By Appointing Authority (or designee)
Annual FML - annual Unpaid Other Specify:
Sick FML – sick ___ Military
STD FML - STD Voluntary Furlough
Bereavement FML - holiday ___ Compensatory Time
Administrative FML - unpaid
Jury FML - Military Caregiver
Alt. Holiday FML - Military Family
___ FML - Compensatory
A Medical certification is required is not required. (Required for more than 3 full consecutive working days.)
A Fitness-to-Return certification will be will not be required before returning to work on a regular basis. (Required for an absence of more
than 30 days.)
Approved by Date
Immediate Supervisor or Designee Signature
Approved by Date
Appointing Authority, Designee, FML Coordinator Signature
Posted by Date
1 Revised 2/18/11
Print Form
DEFINITIONS
Complete definitions of the various types of leave and the rules governing their use are found in Chapter 5 of the State Personnel Director's
Administrative Procedures (rules) at http://www.colorado.gov/dpa/dhr/rules/rules.htm
. Additional information and assistance is also available
in human resources offices.
The appointing authority is responsible for approving the use and type of leave.
The employee is responsible for requesting leave as far in advance as possible and providing sufficient information regarding the reason for the
leave.
Please be accurate. Specify actual dates and times to be charged as leave. Incorrect information may cause errors and delays in processing an
employee's request for leave.
LEAVES
Annual Leave - paid leave typically used for personal/vacation purposes. Required to use concurrently when family/medical leave applies.
Sick Leave - paid leave used for an employee's own medical examinations and treatment, physical inability to work due to pregnancy, illness or
injury. Required to use concurrently with family/medical leave. A State of Colorado Medical Certification form is required for an absence of more
than three consecutive regularly scheduled full working days or approval paid leave must
be denied (per Colorado statute). It may be required for a
lesser period.
STD (Short-Term Disability) Leave - After one year of service, granted while STD benefits are being paid and the employee applies for the STD
benefit within 30 days of the beginning of the absence or at least 30 days prior to the exhaustion of all accrued sick leave. Must complete a waiting
period or exhaust all accrued sick leave, whichever is longer. During the waiting period, required to use sick leave and annual leave.
Unpaid Leave - The appointing authority may approve unpaid leave. This may result in an adjustment to the probationary or trial service period.
Administrative Leave - paid leave used for investigation into an employee’s conduct, incentive awards, coursework at a higher education institution
directly related to the work, to participate in tests and interviews for state positions, to participate in school or community volunteer activities, or
other reasons the appointing authority deems for the good of the state.
Bereavement Leave – Employees may request up to 40 hours (5 working days). Employees and supervisors have a mutual responsibility to engage
in a dialogue to determine the amount of leave necessary for the death of a family member or other person.
Jury Leave - Used when an employee is called to serve jury duty. A copy of the summons for jury duty may be required.
Family/Medical Leave (FML) - After one year of service, up to 520 hours in a fiscal year (prorated for part-time employees) may be used for (1)
birth and care of a child, (2) placement and care of an adopted or foster child, (3) a serious health condition of a child, parent, spouse, (4) the
employee's own serious health condition, (5)active duty family leave for qualifying exigency directly related to, being called to, or on active duty to
a foreign country, or (6) up to 26 weeks (1040 hours) in a single 12-month period for military caregiver leave for servicemember who is serious ill or
injured in the line of duty on active duty. Use and type of concurrent paid leaves depends on individual circumstances. For additional information,
contact the FMLA Coordinator. An appropriate State of Colorado Medical Certificate form, as described above under sick leave, is often required.
FML - annual: use of paid accrued annual leave when sick leave is exhausted or does not apply, including caring for a new child.
FML - sick: use of paid accrued sick leave for an employee's serious health condition, including childbirth and recovery or for a
serious health condition of an employee’s parent, spouse, or child.
FML - STD: use of STD leave for a serious health condition when an employee is eligible for STD benefits.
FML - unpaid: use of unpaid leave during family/medical leave when all other applicable paid leaves are exhausted.
FML - holiday: when a holiday occurs during a block of family/medical leave or the employee is scheduled to work the holiday the
leave counts toward the family/medical leave entitlement.
FML – compensatory time: use of compensatory time during family/medical leave.
ABSENCE
Compensatory Time - hours earned for approved overtime work by an eligible employee. Compensatory time is an absence from the work place,
but is not a form of leave. Required to use concurrently when family/medical leave a
pplies.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.
To comply with this law, we are asking that you not provide any genetic information when completing the leave request form. “Genetic
information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic
tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus
carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.
2 Revised 2/18/11
