Family And Medical Leave Act Request Form (Fmla)
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2FAMILY AND MEDICAL LEAVE ACT REQUEST (FMLA)
Please note: Request for Family Medical Leave must be made, if practical, at least 30 days prior to the date the requested leave is to begin.
Name:
Employee Number:
Department:
Title:
Reports to:
Status:
Full‐Time
Part‐Time
Temporary
Today’s Date:
Hire Date:
I request/You are placed on family or medical leave for one or more of the following reasons: (select at least one reason)
Expected date of birth: _________________________
Because of the birth of my child and in order to care for him/her. >
Actual Date of Birth, if applicable: _________________
Leave to start on: ______________________________
Expected Return Date: _________________________
Because of the placement of a child with me for adoption or foster
Date of Placement: ____________________________
care . . . . . . . . . . . . . . . . . . . . . . . >
Leave to start on: ______________________________
Expected Return Date: __________________________
In order to care for my spouse, child, or parent, who has a serious
health condition. Describe serious health condition:
Leave to start on: ______________________________
__________________________________________________________
Expected Return Date: __________________________
__________________________________________________________
**ATTACH MEDICAL CERTIFICATION FORM**
For a serious health condition that makes me unable to perform my
job. Describe serious health condition:
Leave to start on: ______________________________
_________________________________________________________
Expected Return Date: __________________________
_________________________________________________________
**ATTACH MEDICAL CERTIFICATION FORM**
Because of a qualifying exigency arising out of the fact that your
spouse; son or daughter; parent is on active duty or called to
Leave to start on: ______________________________
active duty status in support of a contingency operation as a member of
Expected Return Date: __________________________
the National Guard or Reserves . . . . . . . . . >
In order to care for my family member (spouse, son, daughter,
parent, or next of kin) who has an injury/illness received while on active
Leave to start on: ______________________________
duty that may render the service member medically unfit to perform the
Expected Return Date: __________________________
member’s duties. Attach appropriate certification form . . . . . . >
Proposed leave schedule (including type of leave to be taken and the
Number of hours (May be an estimate):
number of hours) . . . . . . . . . . . . . . . . . . >
________ FMLA Sick Leave
(May be subject to supervisor/employer’s approval.)
________ FMLA Vacation Leave
________ FMLA Personal Leave
________ FMLA Leave Without Pay
Have you utilized family and medical leave in the past 12 months? Yes No If yes, how many days? ______
EMPLOYEE’S SIGNATURE/DATE:
FOR BUREAU OF HUMAN RESOURCES USE ONLY:
APPROVED _____ DISAPPROVED _____
HUMAN RESOURCE MANAGER:_____________
Rev. 11/12
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