FMLA Employee Request Form

To request leave on the basis of the Family and Medical Leave of Act (FMLA), please completethe following request form and submit to Human Resources at least 30 days prior to leave(unless leave is unforeseen, in which case submit the form as soon as practical).

Please select

Employee First / Last name

Email address

Phone number

Address

I prefer for all necessary paperwork to be sent to me by:

Please choose your preference.

Clear choice

Mail

Requested Leave Start Date:

If you do not have an exact date, please provide your best estimate.

Estimated Leave End Date:

Leave blank if you do not know when you will be returning from leave.

The reason for this requested FMLA leave is:

Choose the most appropriate box.

Clear choice

Birth of a son or daughter and to care for the newborn child.

Placement with the employee of a son or daughter for adoption or foster care.

To care for the employee's spouse, son, daughter, or parent with a serious health condition.

A serious health condition that makes the employee unable to perform the functions of the employee's job.

A qualifying exigency arising out of the fact that the employee's spouse, son, daughter or parent is a military member on covered active duty (or has been notified of an impending call or order to covered active duty status).

To care for a covered servicemember with a serious injury or illness if the employee is the spouse, son, daughter, parent or next of kin of the covered servicemember.

Time off work is expected to be:

Choose the most appropriate box.

Clear choice

For a continuous block of time (several continuous days, weeks or months off work).

For a reduced work schedule (change in work schedule needed—fewer hours per day or fewer hours per week).

On an intermittent basis (periodic time off that is not usually expected to be the same days or time off from week to week; examples may be time off for flare-ups of a medical condition and/or for ongoing medical treatment/appointments).

Signature

Verification