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Get University Of Chicago Victims Economic Security And Safety Act (VESSA) Leave Of Absence Request Form 2015-2024

Est Form PLEASE PRINT Employee Name: SSN: Home Address: City, State, Zip: Job Title: Dept. Name: REASON FOR LEAVE REQUEST Domestic or sexual violence of employee Domestic or sexual violence of family or household member Name of individual: Relationship: EXPECTED DURATION OF THE REQUESTED LEAVE BLOCK OF TIME from to (month/day/year) (month/day/year) INTERMITTENT LEAVE*: Describe anticipated frequency and duration REQUEST TO USE AND CONTINUE BENEFITS I request to use the following pa.

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