Uthealth Request For Family And Medical Leave Form

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Request for Family and Medical Leave

Name:____________________________________________ Date of Request:________________________________

(30-day notice if applicable)

Title:_________________________________Unit/Dept:__________________________________________________

EMPLID:____________________________ Phone: ___________________Shift: ______________________

Percentage of Worktime: ___________________ Supervisor’s Name:________________________________________

Have you worked for UTHealth for the past 12 months? YES___ NO____

Are you a direct transfer from another State of Texas agency/institution? YES____NO____

If YES, how many years/months were you employed by that agency? ______Years ______Months

If NO and you have 12 months total service with the State of Texas*, how many years/months were you employed by

another state agency? _______Years _______Months

*Prior to commencement of your leave, you must have worked at least 12 months with the State of Texas and worked at

least 1,250 hours during the 12-month period immediately preceding the leave.

Address (while you are on leave):____________________________________________________________________

Telephone Number (while you are on leave): (

) ____________________________________________________

I request permission to be absent from _________________________ through __________________________OR

I request to be absent on an intermittent or reduced schedule from _____________________ through_______________

Note: You must return completed, applicable certification form.

REASON FOR LEAVE: I am requesting family or medical leave for the following reason(s):

For the birth of my son/daughter and care after the birth. **

For the adoption or foster care of my son/daughter. **

For the serious health condition of my spouse, child (under 18 years of age) or parent.**

For my own serious health condition (which makes me unable to perform the essential functions of my job).

Qualifying exigency arising out of the active military duty or call to active military duty of my spouse, son,

daughter, or parent.

Serious illness or injury of a covered service member/covered veteran who is my spouse, son, daughter, parent,

or next of kin.

**Complete Family Relations Information

See Page 2 for definitions.

FAMILY RELATIONS INFORMATION

Spouse Information:

Is your spouse employed by UTHealth? YES_____ NO_____ (

if yes, answer b and c)

Indicate the spouse’s EMPLID: _____________________

Has the spouse taken family/medical leave within the past 12 months? YES_____ NO_____

(Note: If your spouse is also employed by UTHealth, both you and your spouse are limited to 12 workweeks combined if your leave

request is for birth or adoption reasons).

Family Member Information (related to your leave).

Name:_______________________________________ Relationship:____________________ Age of child:__________________

Please Read Carefully Before Signing, I acknowledge the above information and all other information otherwise given by me (pertaining to family or medical

leave), is true, complete, and not misleading in any way. I understand that any incorrect, incomplete or false statements furnished by me may result in sufficient

cause for denial of leave and/or disciplinary action. I hereby grant permission for UTHealth to verify information furnished by me regarding family or medical leave.

I acknowledge that I have read and understood the information on this document, and agree to comply with the rules and regulations outlined therein. I also

understand that my employment with UTHealth may be terminated upon my failure to return to work on the expected date of return or upon the expiration of all my

FML and leave entitlements.

_____________________________________________________

_________________________________________________

Employee Signature

Date