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Notice of Leave of Absence

This form should only be used to put an employee in an unpaid "inactive" status.
SECTION I: Employee and Department Information
SECTION II: Reason and Dates for Leave of Absence
(1) Last Day Worked: Last day the employee is at work providing service for MUSC.
(2) Last Day Paid: Last day the employee received compensation at work or in an approved paid leave status.
(3) Expected Return Date: Date when the employee is expected to return to work.
SECTION III: FMLA Eligibility Verification
Steps Completed
SECTION IV: Department Approval
Fields marked with * are required.
This form will be emailed to the appropriate HR Records Specialist and Payroll. You do not need to print and send this form to HR. [Form Revised 05/2013]

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