Free Sample Leaves Of Absence Without Pay Policy
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Sample Leaves Of Absence Without Pay Policy

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Leaves of Absence Without Pay

Policy Rationale

ABC recognizes the importance of helping employees balance the demands of work, family, and personal needs.  ABC leave policies help employees meet their family and personal needs in a way that satisfies the legitimate interests of ABC and the needs of the employee.

To allow employees to temporarily leave active employment and return to ABC within a specified time and to allow for the continuation of benefits during this time.

Types of Leaves:

·         Family Medical Leave.

·         Personal Leave of Absence.


Family and Medical Leave (FML) helps employees balance the demands of work, their personal family needs in a way that accommodates the legitimate interests of ABC.


FML provides eligible employees with up to enter number of weeks weeks of unpaid time away from work during each fiscal year for the following reasons:

·         Caring for a child after birth, or adoption or placement of a child with an employee for foster care.

·         Caring for a family member who has a serious illness, injury or health condition.

An employee’s position cannot be filled on a permanent basis during the leave period.


All employees, including temporary or casual employees, employed by ABC for at least enter number of months  months are eligible.

Supervisor Roles and Responsibilities

Supervisors will determine if an employee’s request qualifies as FML.  Supervisors notify employees verbally or in writing of the approval.  In addition, supervisors must provide employees with the FML Approval Form within  days of the notification.

Supervisor may designate leave as FML after an employee has returned to work in only two situations:

·         The supervisor does not learn the reason for the absence until the employee returns to work (the leave must be retroactively designated as FML within  business days of the employee’s return to work).

·         The supervisor is unable to confirm that it qualifies under the FML.  Upon receipt of additional information, the supervisor must determine if the leave is designated as FML.

In cases where medical verification is required, OH&S will determine if the medical information is sufficient.  OH&S will notify the supervisor who will in turn tell the employee whether or not the leave is granted.

Employee Roles and Responsibilities

Employees should provide supervisors with at least  days of written notice.

In cases with unforeseen events requiring FML, employees must give as much notice as possible.

If leave is taken and has not been designated FML by the supervisor, the employee must notify the supervisor within  business days of returning to work that the leave was for a family or medical reason.

Paid Leave

Vacation, Personal, Health Care, or Sick Leaves: employees may use these leaves for all or part of the enter number of weeks-week unpaid FML entitlement for the care of a child following birth, a child's placement with the employee for adoption or foster care, or for care of a family member or the like.

Sick Leave: This leave can only be used if the employee is seriously or chronically sick or injured.

Medical Verification

In cases of a serious or chronic health condition of a family member, the leave request must be supported by written medical evidence by a licensed medical practitioner.  The employee will complete a Medical Questionnaire submit it to OH&S within enter number of days days of the request.  Failure to provide the questionnaire result in the denial or cancellation of the leave.

Employees who request FML to provide for a newborn must forward a FML form within enter number of days calendar days of the date of the request to OH&S.  For In adoptions or foster care arrangements, employees must provide a letter from the adoption or foster care agency as verification.  This document must be forwarded to OH&S within enter number of days calendar days of the date of the request.

If medical verification is a requirement of the leave, OH&S will:

·         Notify the supervisor when it receives the FML form or documentation from an adoption or foster care agency.

·         Notify the supervisor if the verification form is not received enter number of days calendar days.

Second Opinion

ABC reserves the right to require an employee to obtain a second opinion at his/her expense.  The second opinion will be through a health care provider chosen by ABC.  If the second opinion differs from the original health care giver's verification/questionnaire, ABC can, at its own expense, obtain a third opinion from a health care provider that is approved by ABC and the employee. The third opinion will be final and binding.

Employment and Benefits

The employee can return to his/her position (provided that it still exists) or an equivalent position.

Employees' health insurance coverage is maintained for the duration of the leave if they elect to pay their share of the premiums.  Nonpayment of the employee's share of the premium will cancel the insurance after 30 days.

Employee Assistance Program (EAP)

Eligibility for the Employee Assistance Program continues during family and medical leave.

Recording And Processing FML

The Employment Advice and Staff Changes Form is required when any FML is taken.

If paid time (e.g. vacation) is used, the department must maintain its normal payroll coding procedures for the use of paid time and must indicate that such time is being used as FML.

Departments are responsible for maintaining current and accurate records of all FML used, whether paid or unpaid.


Chronic or Serious health condition: an illness, injury, impairment, or physical or mental condition that includes:

·         Any period where the individual is incapacitated or subject to treatment due to inpatient care in a medical care facility.

·         Any period where the individual is incapacitated or subject to treatment for more than enter number of days consecutive days that requires continued treatment by a health care provider.

·         Chronic health conditions are serious health conditions even if the family member does not receive treatment and it does not last enter number of days days (e.g. asthma).

Chronic health condition:

·         A long-term condition where treatment is not effective (e.g., Alzheimer's, terminal cancer).

·         Treatment by a health care provider for surgery after an accident or injury, or for a condition that would likely cause incapacity of more than enter number of days if not treated (e.g., cancer or arthritis).

·         Treatment for substance abuse (absence due to employee's substance abuse does not qualify).

·         Requires periodic treatment by a health care provider, continues over an extended period of time, and causes episodic incapacity (e.g. epilepsy).

Health Care Provider: A physician of medicine who is authorized to practice medicine or surgery by State ABC.  This also includes podiatrists, dentists, occupational therapists, physical therapists, naturopaths, clinical psychologists, optometrists, addiction counselors, chiropractors, speech language pathologists, nurse practitioners and midwives and clinical social workers.



A personal leave is an unpaid leave granted at the discretion of the supervisor, for up to a total of enter number of weeks weeks during the fiscal year. Leave may be granted for the following reasons:

·         Educational and developmental opportunities.

·         Exceptional personal circumstances.

·         Government or public office service.

·         Other reasons deemed appropriate by ABC.

During the leave period, the employee maintains his/her position.


All permanent employees are eligible.

Personal Leave of Absence Provisions

Eligibility for the EAP services will continue during leave.

Leave Balances: Employees have the option to use vacation, personal or health care leaves for all or part of the leave. Paid leaves (sick or vacation) do not accrue during a leave without pay.

Continuation of Benefits: Health insurance coverage can be maintained during the leave if employees pay both their share and ABC’s premiums.

Returning from Leave: Requests to return from a leave before the agreed upon return time must be approved by the supervisor. Employees who do not return when the leave expires will be terminated.

Requests and Approvals: Employees submit a written leave request to their supervisor. If approved, the supervisor will confirm the leave in writing before the leave starts.  A copy of the supervisor's letter will be attached to a Staff Changes Form and submitted to Human Resources.

Acceptance of Employment: Acceptance of any employment inconsistent with this leave may result in discipline, up to and including termination.

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