REQUEST FOR LEAVE OF ABSENCE

Instructions
1. Complete sections A & B.
2. Your supervisor must sign the form in Section C.
3. Fax form(s) to the BSC at (312)222-3256 or email form(s) to HR@Tribune.com as early as possible, but no later than
the 3rd calendar day of absence.
4. You will receive a call from the BSC within 24 hours of receipt of your fax/email.
5. QUESTIONS? Send email to HR@Tribune.com FAX 312-222-3256
Section A – Employee Information Please print clearly.
Full Name _____________________________________ Company name ___________________
Employee ID _____________________
Address ________________________________________
Job Title _______________________________________________
________________________________________ Employee Work Week Schedule (circle all that apply):
Phone Number __________________________________ S M T W Th F S
Employee Work Status: ( ) full-time ( ) part-time
Section B – Type of Leave
( ) Disability Leave Last day worked _________________

Type: ( ) Not work-related ( ) Work-related 1st day disabled __________________

Nature: ( ) Illness ( ) Injury -- date of injury ________________ Return to work date _______________
( ) Accident yes/no
**Fax Copy of RTW release 312-222-3256
( ) Check if recurrence of same condition within 14 days of last absence. or email to HR@Tribune.com
( ) Check if leave is on intermittent or reduced-schedule basis for employee’s own
serious health condition.
( ) Pregnancy Disability Leave Last day worked _________________

Estimated delivery date ___________________ 1st day disabled __________________

Return to work date _______________
( ) Check if recurrence of same condition within 14 days of last absence.
( ) Check if leave is on intermittent or reduced-schedule basis. **Fax Copy of RTW release 312-222-3256
or email to HR@Tribune.com
( ) Family Medical Leave (FMLA)
1st day of leave: __________________

( ) Newborn care Expected Date of Delivery _________________ Anticipated return date ______________
( ) Adoption or foster care placement
( ) Serious health condition of ( ) child ( ) spouse ( ) mother ( ) father When employee returns to work, enter date
( ) Military - care of injured service member and fax to the BSC at 312-222-3256 or email
( ) Check if leave is on an intermittent or reduced-schedule basis. HR@Tribune.com:

Return to work date: ______________

( ) Other Leave Type

1st day of leave: __________________
( ) Military Spouse Leave Anticipated return date ______________
( ) Unpaid Personal Leave (*VP approval if leave extends beyond 30 days)
( ) Check if leave is on an intermittent or reduced-schedule basis. When employee returns to work, enter date
and fax to the BSC at 312-222-3256 or email
HR@Tribune.com:

Return to work date: ______________

Section C – Supervisor Approval

Supervisor’s Name (print) ___________________ Phone _________________ Email_________________ __Date ______ ____
Supervisor’s Signature ___________________ __________________________________________
* For PERSONAL Leaves: Dept VP approval (if required or if leave extends more than 30 days)
Dept VP approval _________________________________________________ Date ______________

Section D – Other Contact Names

Timekeeper (print) _______________________________________ Phone _____________________ Email _______________ Date __________
HR Generalist (print) _____________________________________ Phone _____________________ Email _______________ Date __________

Note: You are required to provide address and phone number on this form. Your supervisor must sign the form. Your dept VP must sign the form if your
dept requires it or if your personal leave extends beyond 30 days.