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State of Utah

Department of Human Resource Management

APPLICATION FOR FAMILY AND MEDICAL LEAVE

Revised: 12-26-14

Employee Name:

Dept: __________ EIN:

Home Email:_____________

Work Address:

Work Phone: _____________

___________

Home Address:______________________

____________ Home Phone:

Supervisor’s Name __________________________________

Proposed Start Date of Leave: ______

_____________ Projected End Date of Leave: _______

_______

(Mark approximate dates, not to exceed a total of 480 hrs. 12 wks. or 26 wks. as service member caregiver.)

Is leave being requested as intermittent? Yes___ No___

Is this application 30 days prior to the beginning of leave? Yes___ No___

Reason for Leave:

Is this requested leave for a reason FMLA leave was previously taken or certified? Yes___ No___

It is my intent to return to work. Yes ___ No___

I intend to use my own leave at the same time as my FMLA leave Yes__No__. If no, I intend to use Leave Without Pay__

Approval is contingent upon receipt of the Certification of Health Care Provider, which should be returned directly to the

human resource office. All FMLA qualifying leave used will be counted against the maximum hours allowed. It is your

responsibility to coordinate all leave with your supervisor.

Should you go into a leave without pay status while on FMLA leave, the Department will continue to pay only its share of your

medical, dental, and life insurance benefits under the same conditions as before you went on leave without pay. You continue

to be responsible for your share of medical, dental and life insurance premiums. Current benefits will continue unless you

inform us you do not wish to retain these benefits. If the FMLA leave is taken without pay (LWOP), you shall not be entitled to

the accrual of any seniority or employment benefits during the period of leave.

You must make every attempt to notify the Department at least two (2) working days in advance of the date of your intent to

return from leave. Failure to return to work at the end of the designated leave period may be treated as a resignation unless

an extension has been agreed upon and approved in writing by agency management. If you are medically able to return to

work but elect not to, you may be required to reimburse all health and life insurance plan payments made by the State of

Utah during your leave. Upon returning to work, every attempt will be made to restore you to your original position. If your

original position is unavailable, you will be placed in an equivalent position with equivalent pay and benefits.

You may be required to sign a HIPPA release to obtain the medical clarification necessary when eligibility may be in question.

Failure to provide sufficient information for certification or allow necessary clarification may result in the denial of Family and

Medical leave.

Employee’s Acknowledgement and Agreement _______________________________________ Date:_______________

(Employee Signature)

** All Information Must be Complete and Signatures Obtained Before DHRM Approval **

This Section for DHRM Use Only

12 months employment? (circle one): Yes

1250 hours worked in past 12 months? (circle one):

Yes No

Certified By:______________ Date:

If FMLA is for “Qualifying Exigency” of a spouse, child, or parent or for a “service member” caregiver, was the

appropriate documentation provided? Yes No N/A

(If “No” is circled on any line in this box, the employee is not eligible for FMLA leave.)

Application For Family And Medical Leave - State Of Utah Department Of Human Resource Management

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