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MEDICAL LEAVE REQUEST FORM NOTE: For use only with requests for Family & Medical Leave, Family Illness Leave, and/or leave without pay due to medical reasons (including major disability, and parental

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How to fill out medical leave request form

01

Start by obtaining a copy of the medical leave request form from your employer or HR department.

02

Read the instructions provided on the form carefully.

03

Begin filling out the form by entering your personal information such as your name, employee ID, and contact details.

04

Provide the date on which you intend to start your medical leave.

05

Specify the expected duration of your medical leave, including the start and end dates.

06

Explain the reason for your medical leave in the designated section.

07

If required, attach any relevant medical documents or certificates as supporting evidence.

08

Sign and date the form to acknowledge your agreement with the information provided.

09

Submit the completed form to your employer or HR department as per their instructions.

10

Keep a copy of the filled-out form for your records.

Who needs medical leave request form?

01

Employees who require a medical leave due to illness, injury, or any other medical condition need to fill out a medical leave request form.

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