Transcription of APPLICATION FOR LEAVE OF ABSENCE - michigan.gov
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APPLICATION FOR LEAVE OF ABSENCE - michigan.gov
CS-1845 Rev 10/2020 State of michigan michigan Department of Corrections DISABILITY MANAGEMENT UNIT 206 E. michigan Ave., Box 30003 Lansing, michigan 48909 Phone: 877-443-6362, Fax: 517 -241-6898 Please review the Instructions on the back before completing this form. APPLICATION FOR LEAVE OF ABSENCE Employee Information Employee s NameEmployee s ID Number Home AddressPersonal Email (optional)Cell/Home Phone Number:Work Phone Number: LEAVE Start Date: LEAVE End Date:Intermittent LEAVE or Reduced Work Schedule Supervisor NameSupervisor PhoneDepartment NameReason for LEAVE (check one) A serious health condition that makes you unable to perform the essential functions of your job. A serious health condition affecting yourspouse,child,parent, for which you are needed to provide Parental LEAVE after the birth or adoption of your child. Estimated Delivery Date or Date of Adoption:(Births or adoptions before October 1, 2020, do not qualify for paid parental LEAVE .)
APPLICATION INSTRUCTIONS . If you will be off work for five days or more, you must complete and send this application to the DMU. Indicate the type of leave you are requesting, dates of leave, and leave credits to be used.
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