Fillable Fmla Leave Request Form printable pdf download

FMLA LEAVE REQUEST FORM

Part A: To be completed by employee and/or supervisor, and then submitted to supervisor.

Employee Name _____________________________ Title/Agency/Unit ________________________________

REASON FOR LEAVE:

Birth of a child, or adoption of a child or placement of a child in foster care

Due to the employee’s own serious health condition

To care for a qualifying family member with a serious health condition

To attend to a Qualifying Exigency (QE) for a spouse, parent, son, or daughter of a service member who is

“on active duty (or notified of an impending call or order to active duty) in the Armed Forces (including the

Reserves and National Guard) in support of a contingency operation.”

To care for a qualifying family member who incurred a serious injury or illness in the line of duty while on

active duty in the Armed Forces.

Provide description/details as appropriate:

____________________________________________________________________________________________

TYPE OF LEAVE REQUESTED:

Continuous

Intermittent

Reduced Hours

If FMLA is approved, do you wish to use available sick leave, vacation time and/or compensatory time while on

FMLA?

Yes

If applicable, provide details: _____________________________________________________________________

____________________________________________________________________________________________

Date leave to start:_______________

Date of anticipated return to work:______________

_________________________________________________

________________________________________

Signature of Employee or Representative

Date

Supervisor’s Signature

Date

Part B: To be completed by supervisor, and then submitted to human resource contact.

Employee’s PCN __________ Hire Date __________ Employee’s Classification Title_________________________

I have attached a list of essential job functions for this employee’s position (for FMLA requests arising due to the

employee’s own serious health condition).

_______________________________

_____________________________

__________________

Supervisor Signature

Supervisor Printed Name

Date

Part C: To be completed by human resource contact.

Date agency became aware of employee’s need for FMLA: _________

Are employee and reason for FMLA eligible?

Yes

(Complete appropriate FMLA MOU)

__________________________ _____________________________ ____________________

HR Representative Signature

HR Representative Title

Date

Updated 05/30/13

Fmla Leave Request Form

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