Requesting Short-Term Disability

Please complete the following request for a Leave of Absence. If you have multiple leave requests, you will be asked to complete this survey multiple times. Be advised that your medical documentation may be referred to County Personnel who administer FMLA, Workers' Compensation, ADA, Short Term Disability or Long Term Disability.

Human Resources Leave Administration may be contact by email at or by phone at 520-724-8076.

A Note on FMLA
You may be eligible for Family and Medical Leave Act (FMLA).FMLA is the federal law that requires employers to provide eligible employees with up to twelve (12) workweeks of unpaid, job-protected leave in a 12-month period for qualifying family and medical reasons. It is the policy of Pima County to comply with the provisions of the FMLA and the relevant regulations. HR-FMLA is responsible for processing all requests for FMLA related leaves for Pima County Departments, with the exception of the judicial departments.

Employees are eligible for FMLA if they have been employed by Pima County for at least one year and worked a minimum of 1,250 hours in the previous 12 months. For additional information see the Employee Rights and Responsibilities notice, Employee's Guide to the FMLA and Pima County Administrative Procedure 23-37.

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Who is submitting this request for Short-Term Disability?
Please enter your EIN.
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Please select the leave type from the list of options. If you have more than one type of leave, you will need to complete multiple requests.
Please select whether you expect to be out on continuous or intermittent leave.
Please enter your estimated start date.
Please enter your estimated return to work date.
If you responded "Yes" to the previous question, please enter your new hours per week.
Do not include any medical information or conditions on this form.
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