Family Or Medical Leave Request Form
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1FAMILY OR MEDICAL LEAVE REQUEST FORM
INSTRUCTIONS FOR THE EMPLOYEE
Complete the form and submit to HR.
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You will be notified as to whether the leave is approved or not.
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EMPLOYEE INFORMATION
Employee Name
Employee Number
Title
TYPE OF LEAVE
I hereby request the following type of leave:
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Family leave for the:
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Birth of my son or daughter
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c
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Placement of a child with me for
adoption
foster care
Anticipated date of birth or placement:_________________________________________________________
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Family leave to care for a spouse, son, daughter, or parent with a serious health condition
Family member's full name:__________________________________________________________________
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Relationship to you:
spouse
parent
son or daughter
other (if applicable)
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Medical leave for my own serious health condition (specify): ________________________________________
______________________________________________________________________________________
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Servicemember Care
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Exigency Leave
AMOUNT OF LEAVE
(1)I request that the leave be granted for the following period of time:
Beginning on (date):_____________________________ Ending on (date):_____________________________
(2)I further request that the leave be granted for the following reduced or intermittent leave schedule:
_______________________________________________________________________________________
(3)I would like to substitute the following paid leave time, if applicable, during my family or medical leave:
Type:_________________________________________________ Amount:__________________________
EMPLOYEE CERTIFICATION AND SIGNATURE
I hereby certify that the information given above is true and correct to the best of my knowledge. I understand that
misrepresentation or omission of the reason for leave or any of the facts supporting the need for leave will result in
denial of the leave and will subject me to discipline up to and including termination.
Signature:_________________________________________________Date:____________________________
MAINTAIN THIS FORM IN A FMLA CONFIDENTIAL FILE
HR USE ONLY
Leave Approved?
Expected Return Date
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Yes
No For what period?_____________________
The following paid leave will be substituted:
Insurance premium to be paid as follows
Remarks:
Signature
Title
Date
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