REQUEST FOR EXTENDED LEAVE OF ABSENCE
Missoula County recognizes that employees may need to take extended leaves of absence for
maternity or other planned medical reasons. The following provisions set forth Missoula County’s
requirements for requesting and using such leave. These procedures are intended to help employees
and supervisors ensure that appropriate notification and approval is given for such leave and to
ensure there is no loss, reduction or delay in insurance and leave benefits.
Employees should submit requests for leave for planned medical reasons including maternity
at least 30 days prior to beginning such leave. If thirty days advance notice is not possible the
employee must request leave as far in advance as possible.
Requests for anticipated leave are to be given to the employee’s supervisor in writing.
Departments may require a specific format for such requests or use the form included with this
information. Employees must receive written supervisory approval before they begin leave.
If requests for leave exceed the employee’s available paid leave, the employee must contact
the Human Resources Office before beginning such leave to: coordinate paid and unpaid
leave; arrange payment of insurance premiums; and discuss other issues related to an
extended leave of absence. Requests for donations of sick leave may be submitted in
accordance with county policy following the respective department’s procedures.
If the leave of absence is related to an injury covered by workers compensation, the employee
must contact the Workers Compensation Coordinator in the Risk and Benefits Office to ensure
approval and coordination of benefits.
Except for standard maternity leave, medical certification may be required prior to the
employee returning to work. County return to work procedures will be followed if the employee
will be returning to work on a restricted or modified duty basis.
In accordance with County policy 400.00, failure to follow County guidelines or requirements
regarding extended leave requests may result in corrective or disciplinary action.
* * * * * * * * * * *
Name: ____________________________________ Date Submitted: _______________________
Department: ________________________________ Probationary Employee? ( ) Yes ( ) No
Date Leave to Commence: ____________________ Expected Duration: ____________________
Reason for Leave: _________________________________________________________________
Department Approval: _________________________ Date: _______________________________
Distribution: White - Human Resources Yellow – Department Supervisor Pink – Employee
G\HR\WC & Injured Employees\Forms\RequestExtendedLeave.doc