Clear form
Human Resources
Family and Medical Leave Request
To be completed by employee:
Date
Employee name
Job title
Supervisor or Dept. Head
Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to up to 12 weeks of job-protected leave for certain family and
medical reasons. Submit this request form to your supervisor or department head at least 30 days before the leave is to commence, when possible.
When submission of the request 30 days in advance is not possible, submit the request as early as is possible. The employer reserves the right to
deny or postpone leave for failure to give appropriate notice when such denial/postponement would be permitted under federal or state law.
Counting any periods of time you worked for the University of Georgia (whether they were consecutive or not), have you
1.
Yes
worked for UGA for a total of 12 months of more? (If “yes,” continue to question 2. If “no,” stop here. Sign and submit this
No
form to your supervisor or deparment head.)
2.
During the past 12 months, have you worked at least 1,250 hours (approximately eight months of 40-hour weeks or one
Yes
year of 25-hour weeks)? (If “yes,” continue to question 3. If “no,” stop here. Sign and submit this form to your supervisor or
No
department head.)
3.
Have you previously received medical or family leave?
Yes
If yes, provide information below:
No
Dates of leave _______________ to _______________
Purpose of leave
Have you taken any intermittent medical leave?
4.
Yes
No
Have you taken time off from scheduled hours?
5.
Yes
If “yes,” provide details
No
Is your spouse employed by the University of Georgia?
6.
Yes
No
If “yes,” spouse’s name:
Reasons for requesting leave
Leave must be granted for any of the following reasons:
• For a serious health condition that prevents you from performing the duties of your job;
• To care for your child, spouse, or parent who has a serious health condition;
• To care for your child after birth, or for placement after adoption or foster care; or
• Because of any qualifying exigency arising out of the fact that the spouse, or a son, daughter, or parent of the employee
is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a
contingency operation.
• Because you are the spouse, son, daughter, parent, or next of kin of a covered servicemember with a serious injury or
illness
I request leave for the following reason:
Personal serious health condition
Serious health condition of:
spouse
child
parent
Birth of a child
Adoption or placement of a child for foster care:
scheduled date of adoption or placement
Qualifying military exigency involving a spouse, son, daughter, or parent of the employee as described above
I am the spouse, son, daughter, parent, or next of kin of a covered servicemember with a serious injury or illness