Family And Medical Leave Request Form - University Of Georgia Page 2
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2UGA Family & Medical Leave Request Form p.2
Dates of leave requested
I request leave from ____________________ to ____________________
I request intermittent leave according
to the following schedule:
I request a reduced schedule leave
according to the following schedule:
The total number of leave days I request is
Employee statement
I agree to return to work on _________________________________. If circumstances change such that I will not be able to
return to work on that date, I agree to inform my supervisor by submitting a NOTICE TO MY SUPERVISOR. I understand my
benefits will continue during my leave; however, I must arrange to pay my share of applicable premiums.
Signature _____________________________________________ Date ______________________
TO BE COMPLETED BY SUPERVISOR OR DEPARTMENT HEAD/DEAN
Employee or faculty member was hired on __________________
S/he started in this department on ______________________
Employee or faculty member is
Full time
Part time
Current schedule commenced on _____________________ (If there was an earlier schedule, list below):
Employee has previously requested family or medical leave on _______________________
Date
Leave taken from ______________ to ______________
Total time taken ____________
Name of supervisor or department head: _______________________________________
Date: ________________________ Telephone #: __________________________
Faculty members’ completed forms should be forwarded to the Office of Faculty Affairs
Non-faculty employees’ completed forms should be retained in the employee’s home department
Prior leave requests confirmed:
Leave is
Approved
Denied for the following reason(s)
Request approved /denied by: __________________________________________ Date:_________________
• Complete the FMLA Departmental Response to Employee form
• Provide a copy of this form and the Approval/Denial form to the employee
Revised June 16, 2015
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