Family And Medical Leave Request - Augusta University Human Resources Page 2
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2AU 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 and 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 _______________________
Leave taken from ______________ to ______________
Total time taken ____________
Name of supervisor or department head: _______________________________________
Date: ________________________ Telephone #: __________________________
All completed forms should be submitted to the HR Benefits & Data Management Section and will be
maintained in the HR Benefits & Data Management Section.
Prior leave requests confirmed:
Leave is
Approved
Denied for the following reason(s)
Request approved /denied by (department): __________________________________________ Date:_________________
Revised 01/2016
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Parent category: Business