Fmla Leave Request And Approval Form - Edgecombe County

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Edgecombe County
FMLA LEAVE REQUEST and APPROVAL FORM
Employee Name:
SS#:
Home Address:
Job Title:
Department:
Supervisor Name:
Today’s Date:
EMPLOYEE ELIGIBILITY
Employees are eligible for 12 weeks of unpaid leave under the FMLA every 12 months if they
meet both of the following requirements:
They have worked at Edgecombe County for 12 months or more (does not need to
be a consecutive 12 months).
They have accrued at least 1250 work hours (approximately eight months of 40-
hour work weeks or one year of 25-hour weeks) in the last 12 calendar months.
Please check one:
I meet both requirements.
I do not meet both requirements.
Note: Employers have the option to exempt the highest paid 10% of their employees from
FMLA leave since those employees are often indispensable to the well being of the business.
PREVIOUS LEAVES
Have you ever taken leave under the Family and Medical Leave Act?
Yes
No
If yes, provide dates of leave and reason for leave:
Have you ever taken a leave that was NOT under the FMLA?
Yes
No
If yes, provide dates of leave and reason for leave:
REASON FOR LEAVE
I am requesting leave under the FMLA for the following reason:
For a serious personal health condition.
Does your health condition warrant a 3-day absence from work and/or an overnight stay
at a medical facility?
Yes
No
Describe condition here:
- 1 -.

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