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Leave Incidence Reporting Form
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- Location Name REQUIRED Please fill out this field. Please enter valid data.
- Employee Position REQUIRED Please fill out this field. Please enter valid data.
- Employee Gender REQUIRED Please fill out this field.
- Employee Annual Pay REQUIRED Please fill out this field. Please enter valid data.
- Employee Date of Hire REQUIRED Please fill out this field. Please enter valid data.
- Reason for Leave REQUIRED Please fill out this field.
- If family member's serious health condition, who is family member?
- Please provide a brief description of the serious health condition: REQUIRED Please fill out this field.
- Estimated length of leave (in weeks) REQUIRED Please fill out this field.
- Amount of paid leave provided by employer (in weeks) REQUIRED Please fill out this field.
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