Forms Stitch It
Medical Leave / Accommodation Request Form
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Associate's Name
*
Associate Number
*
Email
*
Store Number:
*
Request Type:
*
Medical Leave Request
Extension of existing leave
Returning from an existing leave
Reason for Leave:
*
Medical for Employee
Medical For Family Member
Type of Leave:
Full Unpaid Leave (up to 17 weeks)
Long Term Disability (LTD 18 weeks + upon approval)
To care for the following family member with a serious health condition:
*
Child
Spouse
Parent
Sibling
Has your healthcare provider confirmed that you are fit to return to work?
*
Yes
No
Are you able to resume your full job duties and regular schedule?
*
Yes
No, I will need accomodations
Type of Accommodation:
*
Work Schedule
Ergonomic Equipment
Modified Duties
Other
Reason for the Request: (Please provide a brief explanation, without sharing sensitive medical details. You may attach supporting documents.)
*
Start Date of Leave/Accommodation:
*
End Date (if known):
*
Medical Certification (Required for medical leave/accommodation)
*
Medical Note/ Certificate from a licensed healthcare professional.
Please provide a medical note/certificate from a licensed healthcare professional
*
Drag & Drop Files,
Choose Files to Upload
Employee Declaration
I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that additional documentation may be requested to process my request.
Signature
*
Clear Signature
Date
*
Submit
