University Of Maine System - Request For Family And Medical Leave Form (Fml)


University of Maine System
Request for Family and Medical Leave (FML)
*Personal Email:
*By providing your email address, you agree to receive FML information via email. You may not use your
University email while on leave.
I am requesting a Leave for the period starting _____________________ and ending _________________.
Time Requested: ___________________
____ Hours
____ Days
____ Weeks (check one)
Leave Type: ____ Continuous
____ Intermittent*
____ Reduced Schedule* (check one)
*I am requesting leave in the form of intermittent leave or reduced hours as follows (specify starting and ending
dates and the hours to be taken as leave):
This leave is requested for:
_____Family leave: (check all applicable boxes and certification box if leave is being taken for a
_____Birth of a child (anticipated or actual date of birth ______________________)
_____Care of a newborn child (anticipated or actual date of birth ______________________)
_____Care of a child placed for adoption or foster care (date of placement _____________________)
_____Care of a family member with a serious medical condition:
(circle as appropriate: spouse, domestic partner, child, parent, sibling)
_____If leave is for a child, I certify that I am responsible for the daily care and/or financial support.
_____My own serious medical condition
_____Donation of an organ by the employee for a human organ transplant
_____Military Family Leave because of a qualifying exigency (12 week maximum)
_____Military Family Leave to care for a covered servicemember with a serious injury or illness (26 week
Paid/Unpaid Leave: Available accrued paid leave (both disability leave and annual leave) must be used before you may take an
unpaid family/medical leave, except that you may reserve up to one week of annual leave and may use, but are not required to
use, accrued leave if you are receiving Short-Term Disability benefits. The use of paid disability leave, whether for your own
illness or for family illness, is still subject to University policy and contract provisions. The entire leave, including any paid leave
as well as unpaid leave, is considered family/medical leave and is counted toward the 12 or 26 week entitlement.
I ___do
___do not wish to retain 40 hours of annual leave (applicable if balance exceeds 40 hours.)
You should notify your supervisor each time you will be absent from work. Your supervisor will be notified by HR
the status of your request. You should not provide any medical information to your supervisor.
Employee Signature: ___________________________________________
Please visit
FMLA Notice of Rights and Responsibilities and other important information.
Rev. OHR 04/2016


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