for:

Personal Medical Leave

Leave to Care for a Defined Family Member

A Combination of Personal and Family Leave

Beginning Start Date

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Start Date

I expect to be gone for

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Number of days/weeks

and hope to return

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Date

Add additional details such as the

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Yes, I have spoken to my supervisor and advised them about my upcoming need for PFML leave.

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Signed

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Date

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mm/dd/yyyy

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