County Of Alameda Family And Medical Leaves Employee Request For Leave Form
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COUNTY OF ALAMEDA
FAMILY AND MEDICAL LEAVES
EMPLOYEE REQUEST FOR LEAVE
Employee’s Name: __________________________________ Employee’s ID #: _____________________________________________
Classification: ______________________________________ Department: ________________________________________________
Contact Telephone Number: __________________________ Immediate Supervisor:_________________________________________
This is a request for leave as provided under the Family Medical Leave Act (FMLA)/California Family Rights Act (CFRA) and/or Pregnancy
Disability Leave (PDL).
My requested
intermittent leave is from ______________ through ______________ for the reason(s) indicated below:
continuous
1. My own serious health condition (including industrial and/or non-industrial injury/illness/medical condition).
2. To care for my
spouse/domestic partner
child
parent due to his/her serious health condition.
3. My own disability due to pregnancy, child birth, or related medical condition, or for prenatal care.
(Note: Disability due to pregnancy/child birth/related medical condition is covered under FMLA/PDL only)
4. To bond/care for my new born, adopted child or foster child (child bonding).
Date of birth/placement with my family: ______________
5. Because of a qualifying exigency arising out of the fact that my
spouse
son or daughter
parent who is a covered service
member on covered active duty in the Arm Forces.
6. To care for my
spouse
son or daughter
parent
next of kin who is a covered military member with a serious injury or
illness.
EMPLOYEE ACKNOWLEDGMENT
I certify that the information I have provided above is true and correct.
Employee’s Signature: ______________________________________________________
Date: ____________________________
TO BE COMPLETED BY SUPERVISOR & HUMAN RESOURCES
Upon receipt of this form, immediately complete and forward to your Human Resources Office for processing.
Date Received: ______________ Supervisor’s Signature: _____________________________________________________________
Date Received: ______________ Department Head/HR Representative:__________________________________________________
FML Employee Request (FORM 1)
REV 12/11
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