Family and Medical Leave

Forms

Medical Leave

To apply for medical leave, please complete the application and applicable certification form listed below.


Submit the application to your department's designated HR Partner.
Provide the supporting certification and applicable documents to HRLeaveAdmin@piercecountywa.gov or send by Fax to (253) 798-8558.

Non-Medical Leave

To apply for non-medical leave, please complete the Non-Medical Leave Request application and any qualifying documentation as applicable for request. Please see certifications listed below.


*Non-medical leave examples: unpaid personal leave, military active duty, sabbatical leave.

Submit the application to your department's designated HR Partner or Supervisor.
Provide the supporting certification and applicable documents to HRLeaveAdmin@piercecountywa.gov or send by Fax to (253) 798-8558.
If Family Leave is for...
Complete the Leave Request Application (link above) and the applicable form below:
Employee's own health condition
Certification of health care provider for employee's serious health condition
Family member's health condition Certification of health care provider for family member's serious health condition
Injury / illness of covered military service member
Certification for serious injury or illness of covered service member for military family leave
Qualifying exigency for active-duty military family member
Certification of qualifying exigency for military family leave
 Injury / illness of military veteran Certification for serious injury or illness of a Veteran for Military Caregiver leave