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                          Leave of Absence Request
                          This form is to be completed by employees prior to taking a Leave of Absence which results in changes to
                          employee payroll. For additional information on leaves of absence please refer to Queen's Leaves Policy.

                          Employee Information

                          Employee ID:                                                                                             Department:

                          First Name:                                                                                              Middle Name:
                          Last Name:                                                                                               Queen's Email:
                          Leave Information
                          Family Leaves
                                                  Maternity leave with pay                                 Parental leave with pay
                                                  Maternity leave without pay                              Parental leave without pay

                                                  I plan to work until the baby is born (Please enter Due Date as "Leave Start Date" below)
                                                  It is the employee's responsibility to contact the HR Advisor to confirm actual leave start date upon the baby's birth.
                          Leave of Absence without Pay
                                                  Sick / Medical                                           Compassionate Care (legislated)
                                                  General Leave*
                          Other Leaves
                                                  Self-Funded                                              Other*

                          *If Other or General, please specify type or reason:

                          Leave Start Date:                                                                            Leave End date:                                                              (inclusive)
                                                                   YYYY-MM-DD                                                                                    YYYY-MM-DD

                          Vacation Information
                          If paid vacation time is to be taken at the conclusion of a family leave or leave without pay, please specify:

                          Paid Vacation Start Date                                                                     Paid Vacation End Date (Inclusive)
                                                                                        YYYY-MM-DD                                                                                       YYYY-MM-DD
                          Date of Actual Return to Work
                          Additional Information / Comments:

                          Employee Signature:                                                                                                                                         Date:

                          Supervisor Name:
                          Supervisor Approval:                    Leave Request Granted                                Leave Request Declined

                          Supervisor Signature:                                                                                                                                   Date:
                          Submission Methods
                          If you have filled out this form online, it can be saved as a PDF with Adobe Acrobat. It is recommended that the preparer keep a copy of this form
                          and the supporting documentation. The supervisor shall submit the signed form to Human Resources.
                          Method 1: E-Mail                                            Method 2: Print and Forward Form                                     Supervisor Forwarding Instructions (Academic departments
                                                                                                                                                           only - provide a copy of this of this form to the Faculty Office)
                          1. Complete the form online.                                1. Complete the form online.                                         Mail/Hand Deliver: Queen's University Human Resources
                          2. Save the form as a PDF.                                  2. Print the form.                                                   Fleming Hall, Stewart-Pollock Wing
                          3. E-mail it to your supervisor for approval.               3. Sign and forward it to your supervisor for approval.              78 Fifth Field Company Lane
                                                                                                                                                           Kingston ON, K7L 3N6

                                                                                                                                                           Fax: (613) 533-6196

                          Notice of Collection
                          When complete, this form will contain Personal & Confidential information. This information is being collected under the authority of the Queen's Royal Charter of 1841, as amended. This
                          information will be used to tract and process leaves.

Last Updated: 4/17/2012

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