Homak Intake
Leave of Absence — Pending Investigation
Store 34994
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Employee name (To:) *
Manager name (From:) *
Date *
Nature of the alleged conduct *
Harassment
Discrimination
Retaliation
Other
Brief description of the allegation *
Leave pay/benefits status *
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With pay and benefits
Without pay and benefits
With pay, without benefits
Without pay, with benefits
Employee's point of contact for questions *
Investigator name *
Investigator phone *
Investigator email *
Investigator other contact info
Investigator's preferred contact method *
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