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Leave of Absence Request
This form is used to request a leave of absence.
Please do not complete this form more than 30 days in advance of your first day of absence.
You can contact us at
LOA@iowa.gov
with any questions.
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* Indicates required question
Employee First Name and Last Name
*
Your answer
Employee Work Email Address
*
Your answer
Employee Personal Email Address
Your answer
Supervisor First Name and Last Name
*
Your answer
Supervisor Work Email Address
*
Your answer
Employee ID (5 digit from Workday or last 4 digits from SSN)
*
Your answer
Employee Hire Date
*
MM
/
DD
/
YYYY
Hours worked within last 12 months (Please reach out to your HR Partner for assistance with this.)
Your answer
Have you used FMLA within the past 12 months?
*
Yes
No
Leave of Absence Type
*
Employee (includes pregnancy)
Care for a Newborn, Adoption or Foster Placement
Active Military Duty of 30+ days
Family Member - child
Family Member - parent
Family Member - spouse
Type of Leave
*
Continuous (not working at all )
Intermittent (combination of working & absences)
Estimated Start Date of Leave of Absence
*
MM
/
DD
/
YYYY
Estimated End Date of Leave of Absence
*
MM
/
DD
/
YYYY
Comments
Your answer
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