Family And Medical Leave Request Form
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1
2REQUEST FOR FAMILY OR MEDICAL LEAVE
If possible, a request for family or medical leave must be made 30 days prior to the date requested leave
is to begin.
Name: ________________________________________
Employee ID #: _________________
Address: _______________________________________________________________
Home Phone: ________________________
Work Phone: ________________________
Email: ______________________________
Department: ______________________________________
Status: ______ Full- time
______ Part-time
_____Wage
U.Va. Hire Date: _________________
State Hire Date: _________________
I request family or medical leave for the following reason(s):
_____ BIRTH OF A CHILD
Leave expected to start: __________________ Expected return date: __________________
Expected date of birth: __________________
_____ PLACEMENT OF A CHILD WITH ME FOR ADOPTION OR FOSTER CARE*
Leave expected to start: __________________ Expected return date: __________________
Placement Date: __________________
_____ TO CARE FOR MY SPOUSE, CHILD (UNDER THE AGE OF 18), OR A PARENT THAT HAS A
SERIOUS HEALTH CONDITION*
Leave to start: __________________
Expected return date: __________________
_____ FOR A SERIOUS HEALTH CONDITION THAT MAKES ME UNABLE TO PERFORM MY
JOB DUTIES*
Leave to start: __________________
Expected return date: __________________
Please describe: _________________________________________________________________
_____ FOR MILITARY LEAVE
Leave to start: __________________
Expected return date: __________________
Qualified Exigency ____
Care for Service member ____
_____ Requested intermittent leave schedule (subject to agency’s approval)
Schedule requested: ______________________________________________
_____ Requested reduced schedule** (subject to agency’s approval)
Have you taken family or medical leave in the past calendar year?
____ No
___ Yes
If yes, how many workdays? ____
*A physician’s certification or other documentation may be required.
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Parent category: Business