FMLA Employee Request Form

To request leave on the basis of the Family and Medical Leave of Act (FMLA), please complete the 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).

Employee Name (print clearly): ________________________________________________

Requested Leave Start Date: ________________                Estimated End Date: ____________

The reason for this FMLA leave request is (select the most appropriate box):

❏   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 service member with a serious injury or illness if the employee is the spouse, son, daughter, parent or next of kin of the covered service member.

Time off work is expected to be (select the most appropriate box):

❏   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).

Additional information about employee FMLA rights and responsibilities will be provided to you in writing within five business days after receipt of this notice (unless already provided).  

Determination of eligibility for leave under the FMLA, and/or additional documentation or clarification of documentation, may be required prior to making a final FMLA determination to approve or deny an FMLA leave request. Please contact Human Resources with any questions.

Employee Signature: _____________________________________           Date: _______

                                    Return to Human Resources Department

For HR use ONLY: Date received: __________     FMLA Eligibility Notice sent: _________