Instructions
1. Complete sections A & B.
2. Your supervisor must sign the form in Section C.
3. Fax form(s) to the BSC at (312)222-3256 or email form(s) to HR@Tribune.com as early as possible, but no later than
the 3rd calendar day of absence.
4. You will receive a call from the BSC within 24 hours of receipt of your fax/email.
5. QUESTIONS? Send email to HR@Tribune.com FAX 312-222-3256
Section A – Employee Information Please print clearly.
Full Name _____________________________________ Company name ___________________
Employee ID _____________________
Address ________________________________________
Job Title _______________________________________________
________________________________________ Employee Work Week Schedule (circle all that apply):
Phone Number __________________________________ S M T W Th F S
Employee Work Status: ( ) full-time ( ) part-time
Section B – Type of Leave
( ) Disability Leave Last day worked _________________
( ) Newborn care Expected Date of Delivery _________________ Anticipated return date ______________
( ) Adoption or foster care placement
( ) Serious health condition of ( ) child ( ) spouse ( ) mother ( ) father When employee returns to work, enter date
( ) Military - care of injured service member and fax to the BSC at 312-222-3256 or email
( ) Check if leave is on an intermittent or reduced-schedule basis. HR@Tribune.com:
Note: You are required to provide address and phone number on this form. Your supervisor must sign the form. Your dept VP must sign the form if your
dept requires it or if your personal leave extends beyond 30 days.