Employee Request For Leave Form
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1
2Employee Request for Leave
This form must be completed and returned to the office responsible for Research Foundation personnel before any request
for leave will be approved. Questions about leave or this form should be directed to the office responsible for Research
Foundation personnel.
Part I: Leave Request Data
Employee’s Name: ______________________________ Employee Number: ___________
(please print or type)
Reason for Request: Check one
Birth of Child
Placement for Adoption/Foster Care
Serious Health Condition of Employee (requires form DB-450)
Care for Seriously Ill Family Member (requires Certification of Physician or Practitioner form WH- 380-F)
If checked, provide name of seriously ill family member and relationship to employee
Name: _______________________________ Relationship _______________________
Because of a qualifying exigency arising out of the fact that your spouse, son/daughter, or parent is on
active duty or call to active duty status in a foreign country as a member of the Armed Forces, National
Guard or Reserves. (requires Certification Form WH- 384)
Because you are the spouse, son/daughter, parent or next of kin of a covered service with a
serious injury or illness (requires Certification Form WH- 385)
Because you are the spouse, son/daughter, parent or next of kin of a veteran with a serious
injury or illness (requires Certification Form WH- 385-V)
If checked, provide name of seriously ill family member and relationship to employee
Name: _______________________________ Relationship ____________________
Other Leave. If checked, specify: ____________________________________________
Date the request leave is to begin ___________ Date you expect to return to work ____________
Are you requesting intermittent leave? No ___ Yes ___ If YES, explain intermittent periods.
Are you requesting a reduced work schedule for FMLA leave? No ___ Yes ___ If YES, explain schedule
requested.
Have you previously been approved for leave? No ___ Yes ___ If YES, give the dates of the leave period:
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Parent category: Business