1
Complete section 1, 2 and 3 of the Leave of Absence Request form
2
Complete section I of the Department of Labor (DOL) Health Care Certification form
3
Provide the DOL Healthcare Certification form to your health care provider, who must complete all of section II (including A, B and C).
4
Submit all completed forms via email to benefits@macombgov.org or via fax to 586-469-6974
Helpful tips:
- Employees who are requesting a medical leave of absence for themselves are required to use their sick leave or comp time. The use of PTO for a medical leave of absence for yourself is optional. Once approved, this option cannot be changed unless there is a change or alteration of the leave.
- Provide your personal phone number and email address. If you are out on leave, you may not have access to your desk phone and work email address.
- Section 4 of the Leave of Absence Request Form can be signed by the department head before it is submitted to Human Resources and Labor Relations.