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    Personal LOA Request Form 2023

    Uploaded by

    Asfia Khan

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Personal LOA Request Form 2023

    Uploaded by

    Asfia Khan
    1 views2 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1 views2 pages

    Personal LOA Request Form 2023

    Uploaded by

    Asfia Khan

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    REQUEST FOR PERSONAL LEAVE OF ABSENCE

    I am requesting a Personal Leave of Absence (PLOA) for the reason identified below. I acknowledge that
    PPD may request additional information if needed to understand the reason for the leave. By requesting
    this leave I am certifying that I have successfully completed my Orientation Period and that I am not
    eligible for a medical leave of absence.

    Please read, sign and return this form to the Leave of Absence team via SC Category - Colleague Service
    Center(HR) (service-now.com) as a “Request Leave of Absence” inquiry at least 30 days in advance of
    needing leave when foreseeable but no later than within two business days of your leave.

    Personal leaves are requested when the employee takes more than 4 consecutive weeks off or
    scheduled/planned PTO is requested to extend beyond 4 weeks. Management can approve up to four
    consecutive weeks of PTO. Beyond that, the employee will be put on a Personal Leave of Absence.

    If for any reason your Personal Leave of Absence needs to be extended or dates need to be changed,
    please complete, sign and return this form to the HR Operations team within your open HRConnect case
    as soon as possible.

    Please print and complete all information:

    Person Number Name E-mail Hire Date

    Part-Time Exempt Phone


    Full-Time Non Exempt Work ( ) - Home / Mobile ( ) -

    Address

    Job Title Manager Department

    I am requesting a:
    Short-term leave (90 days or less) Long-term leave (91 days or more)
    Manager approval required Requires Business Unit Leader approval
    Start Date: Start Date:

    Return to Work Date: Return to Work Date:

    Reason for requesting Personal LOA:


    Employee PTO use

    Any regularly accrued PTO is required to be utilized for the first 4 weeks if the balance is available. You will
    need to enter that PTO time in Absence via Mosaic Time and Absences on the dates that fall in the pay
    cycle in which you want the PTO to be paid. All supplemental PTO should be entered prior to the beginning
    of your leave.

    Employee Acknowledgment
    I understand that if approved for a Personal Leave of Absence:

    • I will not accrue PTO, nor will I be eligible for observed paid holidays while on leave.
    • Any missed benefit premiums will be deducted in the next applicable pay period upon my
    return to work for any leave of absence.
    • I am required to communicate periodically with my manager regarding my return to work.
    • If I require an extension of my approved personal leave of absence, I will be requested to
    submit an updated PLOA form with new dates, to be approved by my manager within my
    current HRConnect case.

    Employee Signature: _ Date:

    Manager Signature: __ Date:

    For Personal Leaves of more than 90 days, Business Unit Leader approval is required.

    BU Leader Signature: _ Date:

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