Family Medical Leave Act (Fmla)/illness Leave Of Absence Request Form

ADVERTISEMENT

Detroit Public Schools Community District
Division of Human Resources
Office of Compensation, Benefits & EHS
3011 W. Grand Blvd., 10
th
Fl. Fisher Building, Detroit, Michigan 48202
Office: (313) 576-0080
Fax: (313) 748-6119
FAMILY MEDICAL LEAVE ACT (FMLA)/ILLNESS LEAVE OF ABSENCE REQUEST FORM
Original Leave Request
Leave Extension Request
Employee I.D.___________________________________
First Name______________________________________ Last Name______________________________________________
Home Address__________________________________________________________________________________________
City_______________________________________________________ State________ Zip Code_______________________
Area Code/Home Phone ________________________________ Area Code/Cell Phone________________________________
Personal Email __________________________________________________________________________________________
Position _______________________________________________________________________________________________
School/Worksite_________________________________________________________________________________________
Work Address___________________________________________________________________________________________
Work Phone No.___________________________________________ Work Fax No. __________________________________
Supervisor/Administrator’s Name___________________________________________________________________________
Have you taken any leave of absence in the last 12 months? [
] No [
] Yes
If yes, type of leave (e.g., Workers Comp; FMLA; Illness Leave)____________________________________________________
FMLA REQUESTED FOR (check one):
Employee’s serious health condition
[
] Continuous
[
] Intermittent
Employee’s job injury/Workers Compensation
Serious health condition of spouse, son, daughter, or parent
[
] Continuous
[
] Intermittent
Birth
Adoption
Exigency for Military Family Leave
Serious injury or illness of covered service member
Leave Requested: From____________________________________________To____________________________________
Employee’s Signature______________________________________________ Date__________________________________
(Rev. 03-2017)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Family Medical Leave Of Absence Request Form Family Medical Leave Of Absence Request Form Business
Suffield Public Schools Family And Medical Leave Of Absence Request Form Suffield Public Schools Family And Medical Leave Of Absence Request Form Business
Non-medical Leave Of Absence Request Form - Northeastern University Non-medical Leave Of Absence Request Form - Northeastern University Business
Request For Family/medical Leave Of Absence Form Request For Family/medical Leave Of Absence Form Business
Request For Family/medical Leave Of Absence Form Request For Family/medical Leave Of Absence Form Business
Family And Medical Leave Of Absence Application Form - Washington University In St. Louis Family And Medical Leave Of Absence Application Form - Washington University In St. Louis Business
Leave Of Absence Request Form - City Of Sacramento Leave Of Absence Request Form - City Of Sacramento Business
Leave Of Absence Request Form - St George's C Of E Primary School Leave Of Absence Request Form - St George's C Of E Primary School Business
Leave Of Absence Request Form - Cal State La California State Leave Of Absence Request Form - Cal State La California State Business
Leave Of Absence Request Form Leave Of Absence Request Form Business

Related Categories

Parent category: Business
Download
Go