Clemson University Family Medical Leave Act (Fmla) Request Form printable pdf download

CLEMSON UNIVERSITY

Revised 08/07/2007

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FAMILY MEDICAL LEAVE ACT (FMLA)

REQUEST FORM

Please print in black ink.

(To be completed by employee)

ALL BOLDED AREAS MUST BE COMPLETED

NAME ______________________________________________

EMPL ID _______________________

MAILING ADDRESS _____________________________________________________________________

CITY ______________________________________ STATE _________ ZIP _______________________

DEPARTMENT NUMBER _________ DEPARTMENT NAME _________________________________

SUPERVISOR ___________________________________________________________________________

PURPOSE OF LEAVE (Check one)

_____ Employee’s Personal Illness / Type of Illness _____________________________________________

_____ Childbirth _____ Adoption _____ Foster Child

Anticipated date ________________________

_____ Care of Seriously Ill Family Member (Employee’s Parent, Spouse, Child)

-Name of Family Member ___________________________ Relationship ____________________

-Type of Care Required _____________________________________________________________

___________________________________________________________________

FMLA BEGINNING DATE ____________________ FMLA ENDING DATE ______________________

TYPE OF LEAVE TO BE USED DURING FMLA LEAVE (check all that apply).

____

Sick Leave, if available, must be taken concurrently during the FMLA period for personal illness.

____

Annual Leave may be taken concurrently for any period of FMLA after eligible sick leave has been

exhausted or for periods of FMLA that do not qualify for sick leave.

____

Family Sick Leave may be taken concurrently for care of a seriously ill family member—maximum

of ten (10) calendar days per year.

____

Compensatory Time may be taken concurrently for any period of FMLA after eligible sick leave

has been exhausted or for periods of FMLA that do not qualify for sick leave.

____

Leave No Pay must be taken concurrently for any period of FMLA after other leave has been

exhausted. If the Leave No Pay will extend beyond 30 days, a Request for Extended Leave of Absence

Without Pay Form must be completed.

If leave is to be taken intermittently or if there will be a reduced work schedule, describe the schedule.

________________________________________________________________________________________

I certify that the information above is accurate. I understand that I will need to provide necessary medical

documentation for any period of FMLA requested (on back of form) and that I will need to notify my

department and/or Human Resources immediately if any of the information above should change.

EMPLOYEE __________________________________________ DATE ___________________________

As the supervisor of the employee listed above, I am aware that the employee has applied for a Family

Medical Leave Act leave. I understand that any leave taken must also be posted concurrently against the

FMLA accrual. I will notify the Office of Human Resources immediately if I become aware of any changes

to the information above.

SUPERVISOR ________________________________________ DATE ____________________________

Clemson University Family Medical Leave Act (Fmla) Request Form

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