Blank Fmla Application Form
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1FMLA APPLICATION FORM
UIN:
Employee Name:
Dept.:
Faculty or Staff:
Full time/ Part time:
Employee Contact information:
Supervisor:
Email
Department Head/Dean:____________
Phone
Mailing address
Reason for FMLA request: mark one
For Employee use:
For Employee’s family member
Indicate relation:
spouse
child
parent
other
Is request pre-planned 30 days or more prior to FMLA event?
Yes
No
FMLA Request:
Estimated time period:
Continuous leave:
Yes
No
Intermittent leave:
Yes
No
Proposed work schedule discussed with supervisor:
* Please note, for intermittent leave request, your proposed schedule will need to be signed by you,
supervisor and department head/Dean and a copy be attached to this request.
**Please note, for intermittent leave request; if it is determined that intermittent leave would cause a
hardship, or disruption to daily business operations, continuous leave may be granted in lieu of
intermittent leave.
For Supervisor:
Employee/Supervisor conference:
Yes
No
Employee Signature
Date
Transition of duties/reassign work: Yes
No
Work schedule arrangement:
Yes
No
Supervisor Signature
Date
For HR use:
DOH:
Notes:
Hours worked:
________________________________
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Parent category: Business