Oregon Health & Science University Employee Request For Family Medical Leave (Fmla/ofla)
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2OREGON HEALTH & SCIENCE UNIVERSITY
Employee Request for Family Medical Leave (FMLA/OFLA)
(When possible, must be requested 30 days in advance)
Name
Employee ID
Today’s Date
Department
Supervisor _________________________________
Supervisor Ext.
Timekeeper _____________________________________________ Timekeeper Ext.
Instructions
•
Employee: complete and return this form to the Benefits office at OHSU (mail code: Benefits, HR or fax, 503-494-5990).
•
Check all boxes that apply to your request for leave.
•
Read the entire form, sign it, and keep a copy for your records.
Eligibility
Federal Family and Medical Leave Act (FMLA)
Eligibility:
Employees who have been employed at least 12 months and worked at least 1,250 hours
Oregon Family Leave Act (OFLA)
Eligibility:
Employees who have been employed at least 180 days (parental leave) or have been employed at least 180 days and worked an
average of 25 hours per week (other OFLA leave).
Leave Reason
I need to take family leave due to:
Complete and return Medical Certification
My own serious health condition
The birth or the placement for adoption or foster care of a child in my care (“parental leave”)
Anticipated delivery date of child___________________________________________
Anticipated date of physical custody of child_________________________________
A serious health condition of a family member or next-of-kin
Complete and return Medical Certification
Name of seriously ill family member_________________________________________________
Relationship to Employee__________________________________________________________
If child of employee, date of birth___________________________________________________
Is care related to injury sustained during active military duty? ____________________________
Exigent circumstances related to call to active military duty of family member.
Complete and return Certification
Duration of Leave
I anticipate that my leave will start on _____________________. If I take an uninterrupted block of time, I expect that my leave will end no later than
____________________. I request that the leave be taken as
A block of time
Yes
No
Intermittent leave
Yes
No
A reduced schedule
Yes
No
If intermittent or reduced schedule, indicate the expected schedule
Is this leave the result of an on-the-job accident or illness
Yes
No
I prefer to have information sent to:
my OHSU e-mail
my home mailing address _______________________________________
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