I have had a conversation with my supervisor.

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Full Name:

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CWU ID:

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Do you work full time, 12 months ?

yes

no

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Work Phone Number:

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Work Email Address:

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Home Phone number:

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Home Email Address:

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Home Mailing Address:

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Please enter your full mailing address

Supervisor's Name:

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Supervisor's Phone Number:

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Supervisor's Email Address:

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Reasons for leaving

Birth of child

Placement of child for adoption/foster care

My serious health condition

Care for family member with health conditions

Military Family leave

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For which family member?

Spouse

Parent

Child

Self

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Requested Start Date:

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mm/dd/yyyy

Anticipated End Date:

mm/dd/yyyy

If End Date is Unknown, check the box:

Will you be absent from work

Continously

Intermittently

Both

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Employee Signature:

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Signature Date:

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mm/dd/yyyy

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